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BLOOD PRESSURE 

IN GENERAL PRACTICE 



BLOOD PRESSURE 

IN GENERAL PRACTICE 



BY 

PERCIVAL NICHOLSON, M.D. 



WITH TEN ILLUSTRATIONS 
SECOND EDITION 




PHILADELPHIA AND LONDON 

J. B. LIPPINCOTT COMPANY 






Copyright, 1913, by 
J. B. LIPPINCOTT COMPANY 

Copyright, 1914, by 
J. B. LIPPINCOTT COMPANY 



Printed in the United States of America 



FEB 19 1914 



)CI.A36262S 



Introduction 

In issuing this volume it is the aim of 
the writer to furnish to the general prac- 
titioner and surgeon a short treatise on 
blood-pressure entirely from the stand- 
point of its practical significance and value. 

So recent is the whole subject of blood- 
pressure, its significance, the means of de- 
termining it, and its clinical use, and so 
extensive is the literature on blood-pres- 
sure published mainly in journals and 
magazine articles, that the busy general 
practitioner in many cases has not been 
able to learn the methods of its use and 
application in clinical medicine. 

With this in mind the author has re- 
viewed the literature on this subject, util- 
izing only such materials as he deemed of 
clinical value, avoiding what are as yet 
purely theoretic findings. 



vi INTRODUCTION 

This treatise therefore starts with the 
assumption that the writer is dealing with 
a new subject, and an effort has been made 
to present the material given in as simple 
a manner as possible. 

In the text references have been omitted, 
but at the end a number will be found for 
those desiring to study the subject further. 

The entire subject has been expressed as 
concisely as possible, and to some it may 
seem dogmatically treated and much ma- 
terial to have been omitted ; but the author, 
in extenuation, wishes to state that this is 
not intended to be an exhaustive treatise 
on blood-pressure, but a simple exposition 
of the subject easily grasped and from a 
clinical standpoint. 

To facilitate ready reference the dis- 
eases with changes in blood-pressure have 
been arranged in alphabetical order, un- 
der the general headings of hypertension 
and hypotension. 

If this simple volume shall aid the gen- 
eral practitioner to a better understanding 
of the methods of determining the princi- 



INTRODUCTION vii 

pies and some of the practical applications 
of blood-pressure determinations its mis- 
sion will have been fulfilled. 

I wish to express thanks to Dr. Wendell 
Eeber for his kindness in reviewing the 
section on the diseases of the eye, making 
this section as condensed as possible, but 
at the same time giving all the essentials 
for the general practitioner. 

Percival Nicholson 
Ardmore, Pa. 



CONTENTS 

PAGE 

Introduction v 

CHAPTER I 

General Consideration and Technique. 

Historical review 1 

Importance of blood pressure, and conditions 

to which it applies . . . . 4 

Definition of blood pressure 7 

Methods of measuring blood pressure: 

(1) Palpation 8 

(2) Auscultation 9 

Auscultatory blood pressure, sounds, and phases 11 

Auscultation method, on what based 13 

The inertia of mercury, and the relation of the 

oscillation of the column to the accuracy of 

the readings 14 



CHAPTER II 

Blood Pressure Instruments. 

Choice of an instrument 17 

Instruments: 18 

(1) Mercurial. 

(2) Those using other fluid media. 

(3) Aneroid, spring-diaphragm, or dial. 

ix 



x CONTENTS 

PAGE 

Instruments {Continued) : 

(1) Mercurial 18 

(a) Reservoir type 19 

Examples described, "Cook" and 

"Stanton." 
Summary. 

(b) U-tube 21 

Example described, "Janeway." 
Summary. 

(c) Closed tube mercurial 22 

Summary. 

(2) Instruments using fluid media other than 

mercury 23 

(3) Aneroid, spring-diaphragm, or dial in- 

struments 23 

Discussion of. 

Nicholson apparatus 26 

Description of 27 

CHAPTER III 
Basic Factors on Which Blood Pressure 
Depends, Diastolic and Pulse Pressure, and 
Normal Readings. 

Main factors 38 

(1) Cardiac strength. 

(2) Peripheral resistance. 

(3) Elasticity of vessel walls. 

(4) Volume of blood. 
Discussion of. 

Pulse and diastolic pressure 41 

Normal range of pulse pressure. 

Rule to estimate diastolic pressure (Brun- 

ton). 
General discussion of. 
Importance of diastolic and pulse pressure. 



CONTENTS xi 

PAGE 

Normal blood pressure readings 47 

Adults. 
Children. 
Low limit. 

CHAPTER IV 

Physiological Variations in Blood Pressure. 

Location of cuff 50 

Position of patient 50 

Meals 51 

Sleep 51 

Exercise 51 

Nervous and mental stimuli 52 

Altitude 52 

Cardiac cases. 

Phthisis. 

Summary 54 

Edema 55 

Asphyxia 55 

CHAPTER V 

Hypertension. 

General discussion of 56 

Diseases with hypertension: 

Angiosclerosis 59 

Angina pectoris 60 

Arteriosclerosis 61 

Autointoxication 66 

Diabetes 67 

Drugs : 67 

Adrenalin, 68; cocaine, 68; camphor, 
68; digitalis, 68; normal saline solu- 
tion, 69; strychnia, 69; atropine, 70; 
caffein, 70; tea and coffee, 70; ergot 70 



xii CONTENTS 

PAGE 

Diseases with hypertension {Continued) : 

Epilepsy, idiopathic 70 

Exophthalmic goiter 71 

Eye diseases: 71 

Spasm of the retinal vessels, 73; 
cataract, 74; chronic interstitial 
nephritis in relation to the eye, 75 ; 
glaucoma, 76; retinal hemorrhage. . 76 

Gout 77 

Heart disease: 77 

Aortic regurgitation, 77; chronic car- 
diac hypertrophy, 78; cardiac valve 
lesions other than aortic, 78; heart 
with loss of compensation, 79; 
myocarditis, 79; acute endocarditis, 
81; bradycardia, 81; cardiac 

arrhythmia 81 

Increased intracranial tension : 82 

Apoplexy, cerebral thrombosis, de- 
pressed fracture of skull, fracture 
of the base, Jacksonian epilepsy, 
intracranial hemorrhage, tumors 

(rapid growing cerebral) 82 

Nephritis: 83 

Chronic interstitial, 84 ; chronic pa- 
renchymatous, 85; acute nephritis, 
85; 

uremia 86 

Obstetrics and eclampsia 86 

Plumbism 89 

Treatment of hypertension : 90 

Prophylactic, general, vasodilatation, 
and other measures 90 



CONTENTS xiii 

CHAPTER VI 

PAGE 

Hypotension. 

Definition and general consideration of 105 

Diseases with hypotension: 

Acute cardiac conditions and peri- 
carditis 106 

Chronic wasting diseases: Cancer, 

chronic phthisis, anemia 106 

Diseases with a marked loss of fluid: 
Cholera, diarrhoea, dysentery, and 
after profuse vomiting, as in car- 
cinoma of the stomach, intestinal 

obstruction, and peritonitis 106 

Drugs: Alcohol, tobacco 107 

Hemorrhage (extensive) 108 

Acute infectious diseases : 

Diphtheria, 109; pneumonia, 109; rheu- 
matism (acute articular), 112; scarlet 
fever, 112; typhoid fever, 112; acute 

infections of children 115 

Neurological conditions: 

Alcoholic delirium, 115; insomnia, 116; 
acute mania, 116; melancholia, 116; 
neurasthenia, hysteria, etc., 116; 
general paresis, 116; trifacial neu- 
ralgia 117 

Phthisis 117 

Shock and collapse 118 

Syphilis: 

Acute 119 

Tabes dorsalis 119 

Treatment of hypotension 120 



xiv CONTENTS 

CHAPTER VII 

PAGE 

Surgery and Anesthesia. 

Ether 121 

Nitrous oxide 121 

Chloroform 121 

Spinal anesthesia (cocaine) 122 

Operative procedure 122 



CHAPTER VIII 

Life Insurance. 

Statistics 127 

Importance of blood pressure readings in 128 

Factors to be considered 129 

Special cases 132 

Bibliography 135 

Index 141 



LIST OF ILLUSTRATIONS 

PIG. PAGE 

1. Auscultation Method 8 

2. " Cook " Sphygmomanometer .19 

3. "Stanton" Sphygmomanometer 20 

4. " Janeway " Sphygmomanometer ........ 21 

5. " Rogers " Sphygmomanometer 24 

6. " Nicholson " Sphygmomanometer 26 

7. New Nicholson Pocket Sphygmomanometer partly 

open 29 

8. New Nicholson Pocket Sphygmomanometer fully open 32 

9. New Nicholson Pocket Sphygmomanometer sectional 

view 34 

10. Blood Pressure and Temperature Chart 52 



BLOOD PRESSURE IN GENERAL 
PRACTICE 

CHAPTER I 

GENERAL CONSIDERATION AND TECHNIQUE 

HISTORICAL.— Going a little into 
the history of blood-pressure de- 
termination we find it dates back 
to 1828, when Poiselli introduced the first 
U-tube mercurial manometer. 

Shortly after Ludwig devised the Kymo- 
graphion, a manometer connected directly 
to an open artery, and recording on a re- 
volving cylinder; but it was not until 
1876 that a useful apparatus for esti- 
mating blood-pressure in man was used 
by Marey, by which he could determine 
both systolic and diastolic blood-pressure. 
There was, however, no general use 
of blood-pressure apparatus until some 

1 



2 BLOOD PRESSURE 

eleven years later (1887), when v. Bosch 
brought forward his apparatus, consist- 
ing of a small rubber bulb filled with 
water and connected with a mercurial 
manometer; the bulb being pressed upon 
the radial artery until the pulse was just 
obliterated, and the pressure read off the 
manometer, v. Bosch later modified his 
apparatus by using an aneroid in place of 
the mercurial manometer. 

V. Ptoin further substituted on the v. 
Bosch apparatus air in place of water, 
which was a great advance, but both in- 
struments have a large possible error, 
which Tigerstedt claims has reached 78 
mm. 

All our modern apparatus dates from 
1896, when Riva-Rocci, in Italy, used a 
rubber bag, 5 cm. wide, surrounded by an 
inelastic material, completely encircling 
the arm. This cuff was connected by rub- 
ber tubing with a reservoir of mercury 
having an upright capillary tube, along- 
side of which was a mm. scale. Air was 
pumped into the cuff, compressing the 



IN GENERAL PRACTICE 3 

brachial artery until the pulse below the 
band was obliterated, and then, by releas- 
ing the air slowly, he determined when the 
pulse reappeared and thus obtained a read- 
ing of the maximum or systolic pressure, 
shown by the column of mercury in the ca- 
pillary tube. 

All instruments which give accurate 
readings have utilized the principle of the 
pneumatic constricting band, except that 
now the width of the cuff is at least 12 
cm., as the narrow cuffs, such as the orig- 
inal Eiva-Eocci, give too high readings. 
This very important error was shown by 
the work of v. Eecklinghausen to be due 
to the loss of pressure in compressing the 
tissues, and that it could be eliminated if a 
cuff from 12-15 cm. wide were utilized. 
Dr. T. C. Janeway states he has found in 
high-tension cases a 5-cm. cuff to register 
as much as 60 mm. higher than a 12-cm. 
cuff. 

All our modern blood-pressure determi- 
nations, as on the Riva-Eocci instrument, 
are recorded as the pressure measured by 



& BLOOD PRESSURE 

the height of a column of mercury of so 
many mm., or, in other words, mercury is 
the standard on which blood-pressure read- 
ings depend. 

The Importance of Blood-pressure and 
Conditions to Which It Applies.— The 
whole subject is one which has become 
prominent from a practical standpoint, in 
this country in about the last eleven years, 
though it had its beginnings as far back 
as 1828 in Europe. 

It has been, however, only in the last five 
years that the importance of accurate 
blood-pressure readings in their diagnos- 
tic, prognostic, and therapeutic applica- 
tion to general medicine has begun to be 
appreciated, and their value realized by 
the general practitioner. 

Blood-pressure determinations are now 
of so well recognized value in medicine and 
surgery, that one of the important ques- 
tions of to-day is what are their applica- 
tion and meaning in special conditions, and 
how reliable are they when other means 
fail us. 



IN GENERAL PRACTICE 5 

Dr. T. C. Janeway has very clearly ex- 
pressed the matter in a recent article, 
"When Should the General Practitioner 
Measure Blood-pressure?" 

He says, in substance, it should be 
taken: 

(1) In the first examination of every pa- 
tient. 

(2) Occasionally for watching the prog- 
ress of cardiovascular disease and ne- 
phritis. 

(3) Examination for certifying to the 
state of health : in life insurance • in appli- 
cants for the army, navy, police, fire de- 
partment, and in schoolboys engaged in 
athletics ; and he also mentions eclampsia 
and diagnosis in conditions with abdominal 
pain. 

In addition Briggs and Cook show 
blood-pressure determinations to be one of 
the most important aids in diagnosis and 
treatment of eclampsia and cardio-renal 
disease, and their undoubted value, in ty- 
phoid fever, in medication of children; in 
surgery before, during, and after opera- 



6 BLOOD PRESSURE 

tive procedures, and in injuries of the 
head, etc. 

In a paper on diagnosis read before the 
Michigan State Medical Association Dr. 
Richard C. Cabot says: "The next pro- 
cedure, following my personal routine, is 
the examination of blood-pressure. That 
leads me to say something about the value 
of blood-pressure in physical diagnosis. If 
I were allowed to have only two instru- 
ments of precision for my aid in physical 
diagnosis, they would be the stethoscope 
and the blood-pressure machine. 

"I have been saved from wrong diag- 
noses and put on the track of right ones 
more often by that machine than anything 
else I know of, except the stethoscope. 
And I am speaking now, as I spoke all 
along, by the check of the autopsy. 

"I regard the measurement of blood- 
pressure as the most important of all the 
resources that have been added to our 
armamentarium as physicians, in the last 
fifteen years. 

"The measurement of blood-pressure, 



IN GENEEAL PEACTICE 7 

when you are familiar with the method, 
can be made in a minute and a half per- 
fectly well." 

Blood-pressure determinations are of 
value to the specialist in eye and ear con- 
ditions ; in fact, there is no branch of medi- 
cine in which blood-pressure is not signifi- 
cant, and often an aid when other means 
of diagnosis have not been sufficient. 

Definition.— By blood-pressure is meant 
the arterial tension or pressure of the 
blood in the vessels within which it is con- 
tained. 

Systolic and Diastolic. — Blood-pressure 
is divided into the maximum or systolic 
pressure and the minimum or diastolic. 
The systolic is the greatest pressure ex- 
erted and takes place during systole of 
the heart; the diastolic is the lowest pres- 
sure, and occurs in the cardiac cycle just 
at the beginning of the systole, or at the 
end of the diastole, the time when most of 
the blood has passed on through the ca- 
pillaries into the veins. 

Pulse Pressure. — From these we obtain 



8 BLOOD PRESSURE 

11 pulse pressure," which is the difference 
between the diastolic and systolic pres- 
sures. 

Mean Pkessure. — Mean pressure is 
about the average between the systolic and 
diastolic readings, but has little clinical 
value and is seldom used. 

Methods of Measuring Blood-pressure.— 
The apparatus being set up ready to op- 
erate the pneumatic cuff is adjusted 
snugly, and without compression, to either 
the arm or the thigh, usually the arm, tak- 
ing care that the cuff is at the level of the 
heart. The cuff is then inflated until the 
pulse below the constriction is obliterated, 
which is determined by palpating the ar- 
tery. The estimation of blood-pressure is 
then made by either one of two methods: 
(1) The old or Palpation Method. (2) 
The new or Auscultation Method, de- 
scribed in 1905 by Korotkow. 

Palpation Method. — (a) Systolic. — 
After obliterating the arterial pulsation in 
the vessel below the cuff, slowly release 
the air pressure, allowing the mercury to 




Fig. 1. — The auscultation method. 



IN GENEEAL PRACTICE 9 

fall evenly, and note the height of the col- 
umn when the pulsation reappears to the 
palpating finger. This gives the systolic 
or maximum pressure, and will be found 
easy to obtain on all instruments. 

(b) Diastolic. — After taking the systolic 
pressure allow the mercury to fall slowly, 
and note the varying degrees of oscillation 
of the mercury column. Eead the scale at 
the base of the maximum fluctuation and 
it gives the diastolic pressure. 

Or when the first change from a small to 
a full bounding pulse is noted read the 
height of the mercury column, and it gives 
the diastolic pressure. 

Both methods of determining the dias- 
tolic pressure are very unreliable and not 
accurate nor practical in general practice. 

Auscultation Method. — This is an ac- 
curate method for both systolic and dias- 
tolic determinations. — ( a ) Systolic. — As 
in the palpation method, having inflated 
the cuff until the pulse is obliterated, 
place the bell of an ordinary binaural 
stethoscope over the artery just below the 



10 BLOOD PRESSURE 

cuff. Now release the air pressure slowly 
and listen with the stethoscope. When the 
first cardiac beat passes the constricting 
cuff a loud, clear thump is heard and the 
true systolic pressure is obtained by read- 
ing the height of the mercury column. 

(b) Diastolic. — In taking the diastolic 
pressure continue to release the air and 
listen over the artery. The thumping 
sound is followed by a murmur, and then 
by a second thumping sound, which be- 
comes fainter and suddenly disappears. 
At the time the second thumping sound 
becomes fainter, again note the height of 
the mercury column, which gives the true 
diastolic pressure. 

This last auscultation method has almost 
revolutionized the determination of blood- 
pressure, for the diastolic pressure can be 
as easily and accurately determined as 
systolic pressure, a result impossible to 
attain in the past, there being such a large 
personal element in obtaining the diastolic 
pressure that most observers did not at- 
tempt it. 



IN GENERAL PRACTICE 11 

The diastolic and pulse pressure (differ- 
ence between systolic and diastolic) are 
thus accurately determined by this method, 
and are often of even greater importance 
than the systolic. 

Auscultatory Blood-pressure, Sounds 
and Phases.— Placing a stethoscope over 
the brachial artery just below the constrict- 
ing cuff and releasing the air pressure 
slowly, you hear five distinct phases in 
most all cases. 

(1) A loud, clear thump is heard as the 
first wave of blood passes the constricting 
cuff, which gives the systolic pressure by 
reading the height of the mercury column. 

(2) In a short time the first phase is 
followed by a murmur, which lasts for a 
variable period, and constitutes the second 
phase. 

(3) After the murmur a loud, clear 
thump is again heard, constituting the 
third phase, often louder than the first 
phase. 

(4) Then the third phase passes into the 
fourth, which is simply a duller sound 



12 BLOOD PRESSURE 

similar to the third and is probably pro- 
duced by the return of the blood vessel to 
its normal caliber as the air pressure is 
lowered. 

(5) The sounds in the fourth phase grad- 
ually become fainter until you have the 
fifth phase or the disappearance of all 
sound. The end of the third phase or be- 
ginning of the fourth phase gives the true 
diastolic pressure. 

At the present time there has not been 
enough work done on the intensity of the 
sounds of the various phases or their rela- 
tive lengths in mm. of mercury to give any 
positive findings, though much suggestive 
work has been done along this line. The 
intensity of the sounds of the third phase 
being considered of importance in deter- 
mining the cardiac strength, a loud clear 
sound indicating a strong heart and vice 
versa. 

The main information at present ob- 
tainable from the auscultation method is 
the determination of accurate systolic and 
diastolic pressures and from them the 



IN GENEEAL PEACTICE 13 

pulse pressure, by the simple process of 
subtraction, e. g. 

Systolic 160 mm. Hg 

Diastolic 120 mm. Hg 

Pulse pressure 40 mm. Hg 

Of pulse pressure and diastolic pres- 
sures I shall have more to say later. 

Auscultation Method, on What Based. 
— In the auscultation method it is largely 
a question of the physics of fluids, e. g., 
the artery is constricted by means of the 
pneumatic cuff; below it there is no ar- 
terial flow, and the vessel walls are in a 
semi-relaxed condition. The air pressure 
in the cuff is lowered gradually until the 
heart has power enough to drive some 
blood into the relaxed vessel beyond. 
The sudden flow of blood into the 
relaxed vessel sends the wall into vi- 
bration, and a loud, clear thump is 
heard, which gives the systolic pressure. 
In making the diastolic estimation there 
again is a physical condition of a fully ex- 
panded artery above the pneumatic cuff, 



14 BLOOD PEESSUEE 

a constriction under the cuff, and an en- 
largement below. Fluid passing from a 
large tube through a constriction into a 
large opening makes a murmur, exactly 
what takes place, and when the caliber of 
the tube is uniform, or, in other words, 
when the diastolic pressure is able to over- 
come the constriction of the cuff, there will 
be no longer any loud sound. It can easily 
be seen that it makes no difference whether 
the mercury column records each pulsation 
of the heart or not, but that it shows much 
more easily and accurately the correct 
blood-pressure than coidd be read if it 
tvere fluctuating very actively. 

The Inertia of Mercury and the Relation 
of the Oscillation of the Column to Ac- 
curacy of Readings. — Here I wish to make 
clear a point which has created consider- 
able confusion in the past, the relation of 
the inertia of the mercury column to the 
determination of the diastolic pressure, 
and also as to whether it is of importance 
for the column of mercury to fluctuate 
with each pulsation of the heart. Were 



IN GENERAL PRACTICE 15 

we to adhere to the old method of reading 
the diastolic pressure, the lowest point of 
the maximum fluctuation, the mercurial in- 
ertia might be of slight importance, but 
from a practical standpoint it is of little 
significance. 

When we use the auscultation method 
for determining diastolic readings, a 
method now almost universally used, on 
account of its ease and accuracy, the lack 
of fluctuation of the mercury has abso- 
lutely no disadvantage. On the contrary, 
it becomes easier to obtain the true pres- 
sure reading, where the column is not ac- 
tively oscillating, as is the needle of the 
aneroid. 

Confusion has been brought into this 
subject of blood-pressure due to the er- 
roneous idea having been advanced that 
the actual fluctuation of the mercury col- 
umn, or needle of the aneroid, is essen- 
tial, it recording each pulsation of the 
heart. 

If pulsations are to be recorded it is 
better to employ a sphygmograph (where 



16 BLOOD PEESSUEE 

the pulsations could be preserved and in- 
terpreted, as they could not on a blood- 
pressure apparatus), but for the determi- 
nation of blood-pressure the sphygmoma- 
nometer should be used. 

To illustrate this, let us recall a little 
problem of physics : a pump forcing water 
through a pipe gives an intermittent flow. 
Placing an air-dome on the pipe line 
makes the flow continuous beyond the 
dome, but the pressure is equal on both 
sides. So blood-pressure determination is 
a question of iHe pressure existent in the 
arterial system, not of the pulsation of the 
heart. 



IN GENERAL PRACTICE 17 



CHAPTER II 

BLOOD-PRESSURE INSTRUMENTS 

CHOICE OF AN INSTRUMENT. -- 
The number of instruments at pres- 
ent available for blood-pressure 
work is legion, and it is decidedly confus- 
ing to one entering this field to select a 
good practical instrument. 

In his book, "A Clinical Study of Blood- 
pressure,' ' Dr. T. C. Janeway gives the 
following advice on the choice of a sphyg- 
momanometer : 

(1) " Manometer must be of such construc- 

tion as to give permanently exact 

readings. 
No metal manometer yet invented re- 
mains accurate, hence this means the use 
of a properly graduated mercurial one. 

(2) Compressing armlet must have a 

width of at least 12 cm. 



18 BLOOD PBESSURE 

(3) Connections must be practically non- 

distensible tubing. 

(4) It must measure both systolic and di- 

astolic pressure. 

(5) Its application must be simple, and 

require not more than two to three 
minutes. 

(6) It must be at once substantial, light, 

and compact, so that it may be easily 
and safely carried. 

(7) It must not be too costly.' 9 
Instruments.— Every apparatus for de- 
termining blood-pressure belongs in one 
of three classes, those using: 

(1) Mercury. 

(2) Some other fluid medium. 

(3) The aneroid, spring diaphragm or 
dial. 

(1) The mercury type is further divided 
into: 

A. Those having a reservoir; the 
mercury rising in an open end 
capillary tube from a zero point 
and having a scale graduated in 
millimeters. 




Fig. 2. — Cook's modification of the Riva-Rocci sphygmomanometer, showing narrow arm- 
band in place, with cautery bulb-inflator. 



IN GENERAL PEACTICE 19 

B. Those employing the U tube. 

C. Those having a short straight tube 

with a closed end. 

Class A.— To this class belong the "Riva- 
Rocci," the "Cook," the "Stanton," and 
more recently the "Sands," a copy of the 
"Stanton." 

I shall give you a brief description of 
the two simpler forms, the "Cook" and the 
"Stanton." 

The "Cook" seen in cut No. 2 utilizes 
all the principles of the original Riva- 
Rocci instrument, consisting of a constrict- 
ing pneumatic cuff connected with a mer- 
curial manometer, and having a means of 
inflation. The cuff when applied over the 
brachial can be filled with air until the 
pulse at the wrist is just obliterated. 

This is a fairly accurate instrument for 
determining systolic readings, but not hav- 
ing a good air release is not practical in 
determining diastolic pressures. It is in- 
accurate in that it uses a 5-cm. cuff, which 
gives too high readings. 

Though by the use of a jointed tube it is 



20 BLOOD PRESSURE 

fairly compact, the mercury is easily 
spilled and the instrument fragile. Its 
double bulb for inflation is also a constant 
source of annoyance from blowouts. 

Now turning to cut No. 3 the original 
" Stanton" apparatus is seen, a reliable 
instrument, but no longer manufactured. 

(1) It was a large, heavy instrument, 
using a 10-cm. cuff, which gave too high 
readings. 

(2) It was not very portable, requiring 
to be taken apart and set up when used in 
general practice. 

(3) It was difficult not to lose the mer- 
cury. 

(4) It had the same defect as the 
"Cook" apparatus in that it used a double 
rubber bulb for inflation. However, it was 
largely adopted and gave accurate read- 
ings when a wide cuff was used. 

All the instruments of this class have 
their drawbacks preventing their becom- 
ing practical portable instruments. Some 
require the manipulation of screws and 
washers; some are large and heavy to 




Fig. 3. — Stanton's sphygmomanometer, showing arrangement of parts, with cautery 

bulb-inflator. 




Fig. 4. — Janeway sphygmomanometer, attached to arm, showing method of retention of cuff- 
arrangement of momanometer, with Politzer bag inflator. 



IN GENERAL PRACTICE 21 

transport; in all the loss of part of the 
mercury cannot be prevented and the dou- 
ble rubber bulbs are constantly getting out 
of order. 

They, therefore, are not instruments 
suitable for the general practitioner. 

Class J5.— The U-tube instruments. 

In this class are the " Janeway," "Mar- 
tin, ' ' " Mercer, " " Brown, ' ' " Sahli, ' » 
"Faught^' and many others. 

In the cut you can see the " Janeway,' ' 
which is one of the earliest and best known 
of this class. 

This instrument has the advantage over 
many others, in that it uses an accurate 
12-cm. cuff, and hence the readings are 
correct on most of the instruments. 

(1) But in order to carry it, the end of 
the U-tube has to be closed with a cork, 
which is often forgotten and as a result 
the mercury is spilled. 

(2) The mercury often escapes from the 
joint made on the long arm of the TJ 
tube. 

(3) As made now, there is a wide metal 



22 BLOOD PRESSURE 

union which obstructs the reading for some 
30 mm. in the middle of the scale. 

(4) Like all U-tube instruments the 
scale has to be condensed one-half to al- 
low for the descent of one column while 
the other rises, so none can be read closer 
than two mm. 

As glass tubing cannot be blown of uni- 
form caliber there is often a swell in one 
limb of the manometer precluding the mer- 
cury from rising or falling equally in both 
sides and as one column is balanced 
against the other any error is multiplied 
by two. Two instruments recently exam- 
ined were found to vary 40 mm. 

Many of the U-tube instruments are too 
bulky to transport and the others which 
are shorter, using a jointed tube, have been 
condemned by many because a plug must 
be placed in the end of the tube to prevent 
the spilling of the mercury. 

Class C. — In order to attain portability, 
a greatly desired feature in blood-pressure 
apparatus, several instruments have been 
made having a short closed tube with mer- 



IN GENERAL PRACTICE 23 

cury working against the inclosed air, e. g., 
"Hertz," "Roger's Simplex,'' "Oliver." 

These have failed because : ( 1 ) The 
scales have necessarily to be condensed, 
making the readings gross, and further 
this condensation greatly increases any 
error. (2) The scales have to be specially 
standardized by comparison with a mer- 
curial column and, being fixed, cannot be 
adjusted to allow for any change in the 
compressibility of the inclosed air column, 
which varies greatly according to moisture, 
temperature, and climate. 

Type 2. — (Instruments using fluid me- 
dium other than mercury). — These instru- 
ments are too long for portability where 
the open end tube is used or where the 
closed end tube, e. g., "Bendick air- water 
apparatus.' ' They have all the disadvan- 
tages of the closed end mercurial instru- 
ments. 

Type 3. — (The aneroid, spring dia- 
phragm or dial). — In addition there are 
the aneroids or spring diaphragm instru- 
ments, following the old model of the v. 



24 BLOOD PRESSURE 

Bosch apparatus. These, while convenient 
in some respects, as Dr. Janeway says: 
"Need to be standardized frequently by 
comparison with a mercurial manometer, 
which is irksome, and they are difficult of 
repair. 

"Depending, as they do, on a spring 
they wear out and are not dependable. ' ' 

Their lack of dependability is clearly 
shown by Dr. J. W. Fischer, medical di- 
rector of the Northwestern Life Insurance 
Company, when he says in a letter to his 
medical examiners: "The experience of 
this department with the various makes 
of sphygmomanometers has convinced us 
that the use of an instrument registering 
the blood-pressure with a mercurial column 
is preferable, although the spring or dia- 
phragm instruments are satisfactory if oc- 
casionally checked up with a mercurial in- 
strument. ' ' 

The spring aneroid, so-called dia- 
phragm, instruments have solved the por- 
tability problem, but have added many in- 
accuracies, so they are not dependable. 




Fig. 5. — Roger's sphygmomanometer adjusted to arm, showing atomizer bulb-inflator. 



IN GENERAL PRACTICE 25 

The elasticity of a solid is a variable 
quantity at the best. So in the aneroid or 
dial instruments the expansion and the 
contraction lessen the elasticity until no 
dependence can be placed on its reaction. 
To compensate for this loss of elasticity 
the manufacturers make the dial movable 
so the indicator can be set at zero ; * as the 
vitality of the drum or spring is perma- 
nently lessened, the needle does not give ac- 
curate readings at other points, and its con- 
densed scale multiplies the errors. 

The auscultatory method of obtaining 
the diastolic pressure is now well recognized 
as the only accurate and simple method. 
Here, where you are listening over the 
artery for the change of sound, if you ob- 
serve the dial of an aneroid, the needle is 
showing wide excursions, making it impossi- 
ble to determine the correct reading, you do 
not know what point in the excursion of the 
needle to note. This is not the case in a good 
mercurial instrument; the fluctuation is but 
slight. As diastolic readings are as impor- 

* Recently one manufacturer has made instruments 
with the dial fixed, and as a result in many the needle 
does not come to rest on the zero point. 



26 BLOOD PRESSURE 

tant as, if not more so than, systolic, the 
fact that the correct diastolic reading can- 
not be obtained is a serious defect in this 
class of instruments. 

Of these instruments Dr. Richard C. 
Cabot makes the following remarks in a 
paper on diagnosis: "The little instru- 
ments which are widely advertised as be- 
ing very portable are splendid for the first 
few months, but if you do many high pres- 
sures on them, like any other aneroid in- 
strument, they give out. The only reliable 
machines are those having a column of 
mercury, which is a bother to carry 
around, but which is necessary." 

Finding the need for a reliable, accur- 
ate, durable, simple, portable, and inexpen- 
sive mercurial apparatus, the author has 
added one more to what might seem an al- 
ready well-filled field.* 

The instrument shown in cut No. 6 is 

* Instrument described in Journal American Medical 
Association, July, 1911, and later imitated. But these 
copies are all liable to an error of from 10-15 mm. Hg on 
the high readings, due to the fact that they employ a 
much larger capillary tube than my original apparatus, 
and, as they use the same scale as mine, there is no allow- 
ance made for the change in bore of the tube employed. 




Fig. 6. — Nicholson sphygmomanometer. A, steel stopcock; B, needle-valve air release; 
C, metal connection to cuff ; D, stopcock for tube to pump ; E, rubber connection to mercury 
reservoir; F, glass reservoir for mercury; G, metal air pump; H, tube to pump; I, tube to 
cuff; J, pneumatic cuff; K, 260 mm. sliding scale. 



IN GENERAL PRACTICE 27 

simply a short form of mercurial instru- 
ment, utilizing the open-end tube with a 
reservoir and so arranged that the mer- 
cury needs no pouring, and cannot be 
spilled. By the use of a steel stopcock and 
flint glass there is no corrosion of the mer- 
cury. The instrument is only 13% inches 
long, and when closed will fit in the ordi- 
nary doctor's bag. 

Accuracy is maintained by the use of a 
full-length mm. scale adjustable to the 
mercury level, allowing for changes in cli- 
mate and temperature, and by the use of 
a wide, easily adjusted, soft cuff (14 cm.). 

The air pressure is easily and steadily 
released by means of a needle-valve, and a 
metal pump, or single rubber bulb, replaces 
the unsatisfactory double rubber bulb. 

This instrument, as time has passed, has 
shown its failing also in that it is not port- 
able enough. It has become well recognized 
that three qualities are essential in any 
good sphygmomanometer to make it a use- 
ful instrument for both the clinician and 
the laboratory man, namely: (1) Accuracy. 
(2) Portability. (3) Durability. 



28 BLOOD PRESSURE 

Up to the present no syhygmomanometer 
has fulfilled all these requirements. 

The mercury instruments some of them 
have had accuracy and durability, but 
lacked sufficient portability. 

As we have seen, the aneroids or dial in- 
struments, on the other hand, have been port- 
able, but the statements of numerous promi- 
nent physicians have plainly shown their 
shortcomings in point of accuracy and dura- 
bility, so that they cannot be relied upon and 
considered a practical instrument where ac- 
curacy and certainty is the first and great 
essential of all good sphygmomanometers. 

Recently I have invented a new pocket 
sphygmomanometer which I think fulfills all 
the qualities essential to a practical instru- 
ment: Accuracy, Portability, Durability. 

The instrument consists of a metal case, 
which completely encloses and thoroughly 
protects all the metal and glass portions. 
This makes it very durable and eliminates 
the frailty of aneroids and many mercurial 
instruments. The lid, when raised, auto- 
matically locks in the upright position, and 
acts as a support for the instrument. 



IN GENERAL PRACTICE 



29 



By referring to cut No. 7 you will see 
the instrument just after the lid is raised. 
On the lid is securely mounted by metal 




Fig. 7. — New Nicholson sphygmomanometer. A, stopcock for 
pump connection; B, connection for cuff; C, needle valve air release; 
D, connection to reservoir; E, metal holder for glass tube; F, tortu- 
ous glass projection to prevent back flow of mercury; G, glass reser- 
voir; H, glass tube upper section; I, metal clamp for tube; J, folded 
section of metal scale; K, lower section of glass tube; L, metal clamp 
for stopcock; M, stopcock on end of tube; N, handle to stopcock M. 



30 BLOOD PRESSURE 

clips a cylindrical glass reservoir (G), 
partly filled with mercury, into the top of 
which is fused the tortuous capillary tube 
(F). The top of the reservoir is connected 
by a union to the metal piece containing 
the needle valve (C), the metal connection 
(B) and the stopcock (A). The bottom of 
the glass reservoir (G) is connected by a U 
bend with the glass tube (K), which ends 
in the steel stopcock (M) and is fastened to 
the lid by the metal clamps (I) and (L). 
Alongside and parallel to the tube (K) is a 
folded metal scale (J) which hinges in the 
middle. At the edge of the lid alongside the 
glass reservoir is the metal tube (E) contain- 
ing the glass tube (H) with a ground end. 
To operate, raise the handle (N) of the 
stopcock (M), remove the glass tube (H) 
from its holder and insert the ground end 
through the open stopcock (M) into the 
upper end of the tube (K) which is ground 
to fit it. The scale is then opened by rais- 
ing the lower end upward. After it is 
open the scale is adjusted so that the 
(o) is at the level of the mercury in the 
tube (K). 



IN GENERAL PRACTICE 31 

Now, turning to cut No. 8, you will see 
how the unions (A') and (B') are inserted 
into the stopcock (A) and the connection 

(B) respectively. Be sure the needle valve 

(C) is closed and the stopcock (A) is open 
as shown in the cut. 

Place the large end of the soft pneumatic 
cuff on the arm well to the inner side over 
the line of the brachial artery, then wind 
the remaining portion of the cuff around 
the arm, covering each turn by the next 
until the tapered end is reached, when you 
tuck it under the preceding turn, which 
holds the cuff in place. Then inflate the 
apparatus by the bulb until the pulse at 
the wrist is obliterated, and use the auscul- 
tation method for the determination of the 
systolic and diastolic pressures. Simply 
release the air by opening the needle valve 
(C) slightly, while you listen over the line 
of the artery below the cuff and obtain the 
pressures by the auscultation method. 

Though I may seem to repeat, I wish to 
make clear an error frequently quoted: 
" That a mercurial instrument will not re- 
cord true diastolic pressure (minimal)." 



32 



BLOOD PRESSURE 



The fact is the reverse : No instrument 
can give as accurate diastolic, or for that 
matter systolic, readings as an accurate mer- 




Fig. 8. — New Nicholson sphygmomanometer. 

curial apparatus, of which this new pocket 
sphygmomanometer is an example. 

Whether the mercury oscillates with 
every heart-beat is not important, we 



IN GENERAL PRACTICE 33 

are not recording pulsations of the heart, 
but the pressure present, and no one can 
obtain accurately any diastolic pressure by 
trying to determine the lowest point of the 
maximum oscillation of an aneroid needle 
or the lowest point of the maximum fluc- 
tuation of the mercury column (the old 
method). The difference in degree of os- 
cillation at the various points is too slight. 

The correct and accurate way to obtain 
the diastolic and systolic pressure is by the 
auscultation method, the method used by 
all the leaders in medicine to-day. 

One great advantage of this new pocket 
sphygmomanometer is that by the ausculta- 
tion method the simplest, and at the same 
time the most accurate, method for obtain- 
ing blood pressure, the diastolic pressure 
is as easily and accurately obtained as the 
systolic pressure. Also being a mercurial 
instrument, it is more accurate and depend- 
able than is possible with aneroids, which 
are, up to the present, the only other class of 
instruments that are of equal portability. 

To close the instrument, cut No. 7, 
remove the tube (H) and slide it into the 



34 



BLOOD PRESSURE 



metal holder (E). Fold the scale down 
and then remove the unions (A') and (B'). 
The lid will then be found to close by 




Fig. 9. — Vertical section of Nicholson's new pocket 
sphygmomanometer. 



IN GENERAL PRACTICE 35 

making firm pressure on the upper end. 
As you shut the instrument you now find 
the handle of the stopcock (M) prevents 
the closure of the lid, as, until the stop- 
cock is shut, the handle projects beyond 
the end of the case. This is arranged so 
that you cannot fail to close the stopcock, 
thus preventing any loss of mercury. 

When it is shut the instrument fits into 
the morocco-carrying case, the pump and 
cuff alongside it, and, after the case is fas- 
tened, it will slip into the pocket. 

Accuracy, the first essential, is obtained 
on this apparatus by a metal millimeter 
scale, especially compensated for any low- 
ering of the level in the mercury reservoir; 
(2) by the zero (0) point on the scale being 
adjustable to the mercury level, so that the 
readings are not affected by climate and 
temperature; (3) by the scale reading 
directly in millimeters of mercury, and 
being in a vertical line, makes reading 
much easier than where the markings are 
condensed and on a circular dial, as on the 
aneroids ; (4) by reading directly in milli- 
meters of mercury, the primary standard, 



36 BLOOD PRESSURE 

it does not have to be checked up, as ane- 
roids do ; you are always sure of your read- 
ings; no spring aneroid diaphragms to 
weaken and delicately balanced needle ac- 
centuated by a hair spring ; (5) by the use of 
a large column there is no separation of mer- 
cury, and oxidization and capillary errors 
are avoided ; (6) by the use of a steel stopcock 
and flint glass no amalgam is formed with 
the mercury, so no friction ; (7) by a steel 
needle valve there is a perfect air release. 

The mercury remains clean owing to a 
new method of preventing powder from the 
rubber tubes being sucked into the mercury 
reservoir. 

Portability : The entire instrument, 
pump, and cuff fit in a morocco carrying 
case which slips into the pocket. 

Weight : So light that it can be carried 
in the coat pocket or in the hand bag. 

Durability : (1) All parts are thoroughly 
protected by a metal case, not easily broken 
or deranged as aneroids are : (2) By a 
special stopcock no mercury can be lost: 
(3) By special stopcock (A) you have an 
additional safeguard should the rubber 



IN GENERAL PRACTICE 37 

washer in the pump leak slightly, until you 
can replace it with a new washer, the mer- 
cury can be absolutely maintained by closing 
the stopcock. This permits of using the 
arm band to produce Bier's hyperaemia. 
By inflating the apparatus to 50 to 60 mm. 
of Hg. and then closing the stopcock (A) 
you can maintain the pressure for any 
length of time desired. This is impossible 
of attainment on any apparatus not having 
this stopcock. This is the only pocket 
sphygmomanometer which has this special 
feature. 

In addition to the above the apparatus is 
simple to operate, using a wide, soft cuff, 
and has an automatic catch on the lid which 
holds the instrument in the upright position 
when in operation. 

It is as portable as an aneroid, with all 
the accuracy and dependability of the 
mercury column. 

There are several other forms of accur- 
ate instruments, but owing to their ex- 
pense and size they are not available in 
general practice, e.g., the Erlanger, Pachon, 
Uskoff, etc. 



38 BLOOD PRESSURE 



CHAPTER III 

basic factoks on which blood pressure 
depends; diastolic and pulse pres- 
sure ; and normal readings 

IN ORDER to utilize blood-pressure de- 
terminations, and make them of real 
value, it is necessary to understand 
on what they depend as well as what 
physiological factors are involved, and 
variations possible without pathologic 
changes. 

While from a theoretic standpoint there 
are a large number of physiological factors 
to be considered, many of these do not, 
from a clinical standpoint, influence blood- 
pressure determinations to any great de- 
gree. 

Blood-pressure Depends on Four Main 
Factors— (1) Cardiac strength. (2) Per- 
ipheral resistance in the vessels. (3) 



IN GENEEAL PRACTICE 39 

The elasticity of the vessel walls. (4) 
The volume of blood. 

Besides these there are several other 
factors, but they are not of great clinical 
importance, e. g., viscosity of the blood, 
etc. 

The heart during systole, shortly after 
the beginning of its contraction, drives the 
blood out into the aorta. The pressure in 
the aorta then reaches the maximum, and 
shortly after the aortic valves close. The 
pressure from then on until the next sys- 
tole is maintained by the elasticity of the 
vascular walls, and as the blood is being 
forced on through the capillaries, the pres- 
sure gradually falls, and reaches its mini- 
mum at the end of diastole. 

The pressure depends mainly on the con- 
tractile power of the heart, and the per- 
ipheral resistance which it has to over- 
come, the peripheral resistance depend- 
ing on the degree of contraction, or cali- 
ber of the vascular walls, and also on their 
distensibility. 

The caliber of the vascular walls in turn 



40 BLOOD PEESSUEE 

depends on the vasomotor center, the bal- 
ance between vasoconstriction and vaso- 
dilatation, and its close interaction with 
the heart through its nerve supply. 

As can be easily seen, the maximum or 
systolic pressure approximates the intra- 
ventricular pressure, while the minimal or 
diastolic pressure represents the periph- 
eral resistance. The pulse pressure, or 
the difference between the two, represents 
the head pressure driving the blood on out 
through the arterioles e. g. 

Systolic or maximum. . .150 mm. Hg 
Diastolic or minimum. . .120 mm. Hg 



Pulse pressure 30 mm. Hg 

The point to be especially emphasized 
is that the maximum or systolic pressure 
by itself indicates mainly heart strength, 
but equally, if not more important, the per- 
ipheral resistance is shown by the mini- 
mum or diastolic pressure, and the head of 
flow is shown by the pulse pressure. 

In the past very little work has been 
done on diastolic and pulse pressure, a fact 



IN GENERAL PRACTICE 41 

due largely to the difficulty in obtaining 
reliable readings with the instruments 
available and the methods used, but this is 
no longer the case where the auscultatory 
method, already described, is utilized. 

Discussion of Pulse Pressure and Dias- 
tolic Pressure. — Before going further it 
might be well to consider pulse pressure 
(the difference between systolic and dias- 
tolic readings) and diastolic pressure more 
in detail. 

Various figures have been given for the 
normal range of pulse pressure : 

Erlanger 30 to 40 mm. Hg 

Hirschfelder 30 to 45 mm. Hg 

Young 25 to 30 mm. Hg 

It might be better stated by saying that 
the pulse pressure is 35 per cent, of the 
systolic reading where a normal balance is 
present; this gives the diastolic pressure 
as 35 per cent, lower than the systolic. 
While the correct diastolic pressure is at 
the time the second thumping sound be- 
comes dull, the time when all sound disap- 



42 BLOOD PRESSURE 

pears may be much easier to obtain and 
will give readings 4-10 mm. lower, except in 
high pressure case when it may amount to 
from 8-16 mm. In cases of aortic regurgi- 
tation, patients with widely dilated arteries 
and children, the error may be even greater. 

While Lauder Brunton says : " Diastolic 
pressure is to the systolic pressure, under 
normal conditions, as 3 is to 4." This gives 
the pulse pressure as one-quarter of the sys- 
tolic reading. (This is not true when you 
used the auscultation method.) 

He further states : " Diastolic pressure 
has as yet received comparatively little at- 
tention because of the difficulty of ascer- 
taining it, yet it is a factor of great im- 
portance because by its amount and by the 
difference between it and the systolic pres- 
sure we obtain valuable data in regard to 
the strength of the heart and condition of 
the arterioles." 

In substance he also gives the follow- 
ing: 

Pulse pressure depends on the pulse 
rate. If the pulse is slowed more time is 
allowed for the blood to run through the 



IN GENERAL PRACTICE 43 

arterial system during diastole. Diastolic 
pressure will be lowered and pulse pres- 
sure increased. The reverse also applies. 

A weak heart will not raise tension as 
rapidly as a strong one, and the time be- 
tween the end of each systole and the next 
will be shorter, and the pulse pressure 
lower. In a stronger heart the interval 
between systoles is longer, and there is a 
larger pulse pressure. 

Now turning to the blood vessels we find 
when contracting the diastolic pressure re- 
mains high, giving a small pulse pressure, 
and vice versa. 

A low systolic pressure with a large 
pulse pressure shows dilated vessels and a 
probably strong heart. 

A low systolic pressure with a slight pulse 
pressure indicates the heart itself is weak; 
in addition, there is probably some dilata- 
tion of the vessels, though a feeble heart 
with normal vessels could give these signs. 

If there is a high systolic pressure, and 
a correspondingly high diastolic pres- 
sure, giving a normal pulse pressure, we 
may assume there is a normal balance be- 



44 BLOOD PRESSURE 

tween heart and vessels, and a compensa- 
tory condition is present. 

Thus pulse pressure is of the greatest 
value in determining the condition pres- 
ent, whether mainly due to heart or ar- 
teries, and is most important in relation 
to treatment. By observing the changes in 
pulse pressure of our cases under treat- 
ment, we obtain the most accurate idea 
possible of the results that are being ob- 
tained; far more so than when we utilize 
the systolic pressure alone. 

If the systolic pressure approximates 
the diastolic pressure, making a small 
pulse pressure, it is a clear indication of a 
failing circulation. This condition, if con- 
tinued, would cause the systolic (maxi- 
mum) and the diastolic (minimum) pres- 
sures to become the same, at which point 
there would be no pulse pressure and 
death would have taken place, as the car- 
diac strength, shown by the systolic pres- 
sure, would not be greater than the per- 
ipheral resistance, shown by the diastolic 
pressure, and there would be no circula- 
tion of the blood. 



IN GENERAL PRACTICE 45 

It is often of great importance to know 
not so much the pressure the blood is un- 
der when delivered to an organ, but rather 
the velocity of flow, so we can determine 
the amount of blood supplied. Here the 
pulse pressure determination is essential 
for the velocity of the blood stream is 
roughly equal to the pulse pressure regis- 
tered in mm. Hg multiplied by the pulse 
rate per minute. While there are other 
factors present, and this is not absolutely 
correct in every case, yet in general this 
statement is correct, and gives us a very 
good idea of the amount of blood supplied 
to an organ. In general, a diminution of 
pulse pressure means a lessened velocity 
of the blood flow, pulse pressure being in- 
dicative of the head of flow. 

Of all the material in this booklet I con- 
sider a clear conception of pulse pressure, 
its determination, application, and mean- 
ing the most important. 

In the past many observers have been 
satisfied with the determination of systolic 
pressure alone, and wondered why their 
observations were useless in practical di- 



46 BLOOD PRESSURE 

agnosis and treatment; but now the rea- 
son for this discrepancy is made clear 
when we understand the obtaining of 
accurate pulse pressure and its interpre- 
tation. 

The determination and application of 
pulse pressure in blood pressure work 
have changed the entire treatment and sig- 
nificance of the subject, so that now its ap- 
plication to general medicine is wide and 
of a practical nature, directing us to a 
right diagnosis, giving a prognosis and a 
means of carrying out practical and scien- 
tific treatment. 

Blood-pressure readings without the de- 
termination of the diastolic pressure and 
the estimation of the pulse pressure are 
often very misleading, since they furnish 
but a partial estimation, whereas when de- 
termined they give invaluable information 
in numerous medical and surgical condi- 
tions. 

Were the determination of the diastolic 
pressure any longer difficult there might be 
some excuse for not obtaining it and from 
it finding the pulse pressure, but by the 



IN GENERAL PRACTICE 47 

auscultatory method its accurate determi- 
nation has been made so simple, being as 
easily and quickly determined as the sys- 
tolic pressure, that there is no longer any 
reason for not utilizing it and obtaining 
the pulse pressure in every case. 

The taking of accurate blood-pressure 
readings, being so simple, is destined in a 
few years to become a routine procedure 
in hospital and private work, taken and 
charted by the nurse just as at present is 
done in the case of pulse, respiration and 
temperature, and the diastolic and pulse 
pressure will be determined in every case 
in addition to the systolic pressure. 

Normal Readings * — Before turning to 
the consideration of blood-pressure under 
abnormal conditions, let us consider the 
normal variations, that have been deter- 
mined by numerous observers. 

It is well to bear in mind the fact that 
blood-pressure standards cannot be abso- 
lutely fixed, there being considerable vari- 
ation in different individuals. 

* Since this has been written I am glad to say one 
large hospital in Philadelphia has the nurses take auscul- 
tatory blood pressure readings, both systolic and diastolic. 



48 BLOOD PRESSURE 

Age Systolic Diastolic 

Erlanger..l9 to 25 yrs 110 65 mm. Hg 

Hirschf elder— All ages 115-120 75-85 

Janeway — Before mid. life. .100-130 25-40 mm. lower 

than systolic. 
After mid. life. . .130-145 25-40 

Before 2d yr 75-90 

After 2d yr 90-110 

Normal — 

Cook—Before 30 years 120-130 

30 yrs. on 125-140 

Abnormal — 

Before mid. life pressure above 145 mm. Hg 

After mid. life pressure above 160 mm. Hg 

Low Limit — 

Janeway — Male 100 mm. Hg 

Female 90 mm. Hg 

Children— " L. Gordon' ' — Systolic 

MM. 

Under one year 71 

One year 73 

Two years 79.3 

Three years 81 

Four years 83 

Five years 86.5 

Six years 88.5 

Seven years 85.0 

Eight years 93 

Nine years 100 

Ten years 95 

Eleven years 104 

Twelve years 105 

In general it may be stated that females 
are about 10 mm. lower than males. 



IN GENERAL PRACTICE 49 

The lowest blood-pressure readings, ac- 
cording to Hensen, were 40 mm. systolic, 
and lowest possible pressure with recov- 
ery was approximately 55 mm. 

Cook and Briggs consider 60 mm. sys- 
tolic severe. 

Janeway, pressure below 75 mm. sys- 
tolic rare except during operation, when 
it has reached 40 mm. 

The lower limit represents the resist- 
ance of the arterioles, due to the necessary 
vasomotor tone, and is probably never less 
than 50 mm. mercury. 



50 BLOOD PRESSURE 



CHAPTER IV 

PHYSIOLOGICAL VARIATIONS IN BLOOD PRES- 
SURE 

WHERE there are no pathological 
changes present, the following 
factors affecting the blood-pres- 
sure readings are found: 

Location of Cuff. — It is important that 
the constricting cuff shall be on a level 
with the heart ; otherwise the correct read- 
ing is raised or lowered by the effect of 
gravity on the column of blood, according 
to whether the constriction is below or 
above the heart level. If above, the read- 
ings will be too low ; if below, they will be 
too high. 

Position of Patient. — The position of 
the patient in relation to the horizontal is 
also important, systolic pressure being 
8-10 millimeters higher in the reclining 
than in the sitting posture. 



IN GENERAL PRACTICE 51 v 

There is about the same difference be- 
tween sitting and standing posture. The 
diastolic pressure also rises but relatively 
higher than the systolic, and as a result 
pulse pressure is decreased. The pulse 
rate is also increased. The main point is, 
therefore, to always take subsequent read- 
ings on the same patient, in the same pos- 
ture, when possible. 

Meals. — There is a moderate rise in sys- 
tolic pressure and pulse pressure after 
meals, and the pulse rate is increased. 

Breathing. — Deep and forced breathing 
raises blood-pressure during expiration, 
often as high as 10 mm., and lowers it dur- 
ing inspiration. Quiet breathing has no 
effect. 

Sleep. — During sleep the maximum 
pressure is lowered 10 to 20 millimeters, 
due to relaxation and vasodilatation. The 
fall is most marked in minimal pressure. 

Exeecise. — Exercise causes a rise in 
maximum (systolic) pressure, and an in- 
crease in pulse pressure, the rate being 
also increased. If regular exercise is se- 



52 BLOOD PEESSURE 

vere, there may be a rise in blood-pressure 
of from 5 to 10 centimeters, depending on 
the amount of force exerted. 

If exercise is carried to excess and fa- 
tigue ensues, blood-pressure falls, and the 
pulse rate is slowed. 

Nervous and Mental Stimuli. — Pain, 
anger, emotion, and mental effort stimu- 
late vasoconstriction, and cause a rise in 
blood-pressure, especially marked in mini- 
mal (diastolic) readings. The pulse is 
also quickened. 

Mental work causes a marked rise in 
blood-pressure, especially when combined 
with worry and excitement, mental activ- 
ity being roughly proportionate to the 
height of the blood-pressure. 

As excitement and worry cause a very 
marked rise in blood-pressure they are 
often dangerous when the tension is al- 
ready high. 

Altitude. — Blood-pressure rises mark- 
edly with an increase of elevation. An 
elevation of 6,000 feet will give an average 
rise of 10 mm. On returning to a lower 



NAME 



DIAGNOSIS 



1 DATE 












































BL0OSPRB8JRE 


TEMF 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


E 


M 


F 


M 


F 


M 


F 


M 


E 


M 


E 


260 


2O0 












































































































































































? 50 

240 


1$° 
180 






































































































































































































































































































































































































































































































































































































































































































230 
220 

210 


IJO 

! 6 P_ 

150 


.... 






































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































200 


140 


-HO- 






































































































































































































































































































































































































































190 

ISO 
l_70 

j 60 
ISO 

140 


130 

.!?? 
no 

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80 












































































































































































































































































































































































































































































































































































































































































































































































































































































fO?° 






















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































130 


70 








































































































































































































































































































































































































































120 


60 








































































































































































































































































































































































































































1 10 


50 








































































































































































































































































































































































































































IOO 


40 


































































































































































































































































































































































































































_S0_ 

.39: 

70 


30 






































































































































































































































































































































































































































?9. 

10 


-Qf°- 












































































































































































































































































































































































































































































































































































































60 





















































































































































































































































































































































DAYOF DISEASE 






















































































pulse; 






















































































RESPIRATION 






















































































PULSE PRESSURE 






















































































BOWELS 






















































































URINE 






















































| 




























- 



Fig. 10. — Nicholson's blood pressure and temperature 
size 11 }£ x8 l / 2 inches. 



chart much reduced; 



IN GENERAL PRACTICE 53 

altitude there is a gradual return to the 
former level, but the return is much slower 
than in cases of high tension due to worry, 
excitement, exercise, or mental strain. 

Increased blood-pressure in high alti- 
tudes is due mainly to the increased heart 
action, from the rapid respiratory move- 
ments in rarefied air, but also to a minor 
degree to the cooler atmosphere which 
causes a constriction of the peripheral ves- 
sels, increasing the peripheral resistance, 
the increased amount of exercise taken, 
and the greater viscosity of the blood. 

Cardiac Cases. — In cardiac cases cau- 
tion must be used in sending patients to 
high altitudes. 

(a) In the young, free from organic 
heart disease, simply worn out or conva- 
lescent, high altitudes are often beneficial. 

(b) In middle aged and elderly patients 
use care, for if there are arteriosclerotic 
changes or the heart is damaged, high alti- 
tudes are dangerous. Apoplexy or cardiac 
dilatation may ensue as the reserve force 
of both vessels and heart is lacking. 



54 BLOOD PRESSURE 

In Phthisis. — Here high altitude is 
mainly important in relation to hemor- 
rhage. In the young, where the arteries 
are resilient, there is little danger. In 
middle-aged there is a real risk, and if the 
blood-pressure is elevated do not send to a 
high altitude. 

Time Consumed in Taking Readings. — 
If constriction is continued over the vessel 
for one minute you may get a possible rise 
of 5 mm. Hg. Continued compression may 
cause a rise up to 20 mm. In myocarditis 
a lowered pressure results. 

Summary. — Take all readings on the 
same patient at the same time of day, pref- 
erably midway between meals. Have the 
patient in a comfortable position, with 
muscles relaxed, best reclining, but in any 
case make all subsequent observations in 
the same position. Exclude all excitement, 
and see that the patient is mentally com- 
posed, and breathing quietly. Make the 
determinations as rapidly as possible. 

If the above precautions are observed, 
from a clinical standpoint there will be no 



IN GENERAL PRACTICE 55 

important error in the pressure values, 
providing the apparatus is accurate, and 
the auscultation method properly em- 
ployed. 

Blood-pressure is also affected by two 
pathological conditions, not in themselves 
diseases : 

(1) Edema. — Here the reading may be 
too high, due to the pressure required to 
squeeze the fluid out of the tissues. Hen- 
sen reports in one case an error of 20 mm. 
Hg. 

(2) Asphyxia. — In this condition we 
often obtain an extreme rise of pressure 
and, in slighter grades of deficient oxyge- 
nation of the blood, a rise to a less degree. 
This condition must be considered in dis- 
eases of the lung, laryngeal diphtheria, 
etc. 



56 BLOOD PRESSURE 



CHAPTER V 

HYPEKTEETSION 

CONSIDERING hypertension, we find 
that where it is not due to the fac- 
tors we have just considered, or sec- 
ondary to drugs, as digitalis, adrenalin, 
strychnia, ergot, etc., there is an increased 
peripheral resistance in the blood vessels, 
which has been found to depend largely on 
the splanchnics. 

Another important point is the fact that 
continued high pressure cannot be main- 
tained without cardiac hypertrophy, and 
that the increased tension will of itself 
cause changes in the vessel wall, thicken- 
ing of intima and media, and loss of elas- 
ticity, with danger of rupture. 

Cases of hypertension are rapidly be- 
coming more frequent, due, in large ex- 
tent, to the increasing stress and strain of 



IN GENERAL PRACTICE 57 

business life and the associated conditions 
of overindulgence in food, especially pro- 
tein; too rapid eating; the drinking of too 
little water; too little healthful exercise; 
the keeping of late hours, with lack of the 
proper amount of sleep ; the use of undue 
mental effort; and the excessive use of al- 
cohol, tea, coffee, and tobacco. In a word, 
lack of good hygiene. 

Hypertension is often in the beginning 
primary and purely a spastic condition 
prevailing in the arterial system unaccom- 
panied by organic changes in the vessel 
walls, the preliminary stage of a general- 
ized arteriosclerosis. 

It is important to discover these causes 
of hypertension early, as they determine 
the onset of a condition which, if con- 
tinued, will cause serious and permanent 
changes in the vessel walls, which in turn 
produce cardiac hypertrophy, with its sub- 
sequent weakening, followed by failure of 
compensation. These spastic cases are 
nearly all due to a toxemia and can be re- 
lieved by proper regulation of the bowels, 



58 BLOOD PRESSURE 

diet, and mental and physical work. In 
this connection the importance of routine 
blood-pressure determination is evident in 
showing a condition which would otherwise 
not be known until the patient were forty 
or past and permanent damage to the vas- 
cular walls had taken place, sufficient for 
symptoms to develop and cause the patient 
to consult a physician. By routine exami- 
nations these cases would be detected at 
their onset and damage prevented by 
proper prophylaxis. 

Even after organic changes in the ar- 
terial system have been caused there is 
still in most cases some spasm, by the re- 
lief of which great benefit may be derived, 
and the development of more vascular 
changes prevented. 

The treatment of hypertension in detail 
will be considered more fully at the end of 
this section. 

It might be well now to turn to the con- 
ditions in which hypertension is associated 
with pathological conditions and not a pri- 
mary condition in itself. 



IN GENERAL PRACTICE 59 

Angiosclerosis (Dr. T. C. Janeway).— 
"Angiosclerosis" describes a rather com- 
mon class of patients who have a perma- 
nent high blood-pressure with no signs of 
sclerosis or nephritis, even after repeated 
examinations. 

These cases Janeway considers are early 
chronic interstitial nephritis. 

Their discovery is very important in or- 
der to prevent cardiac hypertrophy and 
vascular changes, which are inevitable if 
the condition of high tension is not re- 
lieved. 

Treatment. — Here it is important to 
regulate the diet, eliminate as far as 
possible overwork and worry, keep the 
intestinal tract open, and the bowel 
function active, as many of these cases 
are due to a certain amount of auto- 
intoxication. Sweating is also of 
value. 

Caution. — Do not use vasodilators until 
all other methods fail, or the pressure is 
such that it demands immediate relief, 
there being danger of rupture of the ves- 



60 BLOOD PEESSUEE 

sels; then use nitrates, and if necessary- 
bleed. 

High blood-pressure is often compensa- 
tory and by lowering it harm is done. 

Angina Pectoris.— There are a large 
number of patients complaining of mild 
angenoid symptoms, tightness under the 
sternum, dyspnea on exertion, and belch- 
ing after meals, which are accompanied by 
high blood-pressure. 

These are cases of mild angina pectoris. 

i ' Given angenoid symptoms with marked 
hypertension (systolic 180 mm. or over), 
you are probably dealing with angina pec- 
toris. ' ' ( Janeway. ) 

The reverse of Dr. Janeway 's statement, 
however, does not follow, for while in a 
number of cases there is an associated ar- 
teriosclerosis of the aorta and coronary 
arteries, with a high arterial tension, in 
many cases there are marked attacks of 
angina pectoris without increased blood- 
pressure. No less an authority than Dr. 
James Mackenzie considers that blood- 
pressure is normal or lowered during the 



IN GENERAL PEACTICE 61 

attack, for he says: "I can only infer that 
cases of arterial spasm are very excep- 
tional and their description fostered by 
the relief obtained by the administration 
of amyl nitrite has given a wrong concep- 
tion in regard to the condition inducing an 
attack of angina pectoris. I have found 
during the attack the pulse becomes small, 
soft, and scarcely perceptible, from weak- 
ness of the heart, the heart sounds becom- 
ing very faint. I have also found an ac- 
celeration of the heart rate. I could de- 
tect no change in the heart or arteries, and 
there never was the slightest enlargement 
of the heart coming on during the 
attack. ' ' 

Dr. William Osier gives a good sum- 
mary of this subject when he says : 

"The pulse tension, however, is usually 
increased, but it is surprising, even in the 
cases of extreme severity, how slightly the 
character of the pulse may be altered.' ' 

Arteriosclerosis.— Here our diagnosis of 
the existence of sclerosis rests on the 
palpation of the hardened vessel walls, 



62 BLOOD PRESSURE 

visible tortuosity, or we may reason it is 
present from the sclerosed vessels in the 
eye-ground, the enlarged left ventricle, the 
ringing aortic second sound, with high 
blood-pressure. 

Numerous observations have shown that 
unless the splanchnic vessels or the aortic 
artery above the diaphragm are affected 
there are not likely to be an increased 
blood-pressure and hypertrophy of the 
heart, but whenever the splanchnics are 
sclerosed the blood-pressure is elevated. 

In this condition the systolic pressure is 
greatly increased (159-170 mm. to 250 
mm.). The diastolic pressure increases 
(110-130 mm.), but not proportionately, 
thus increasing the pulse pressure greatly 
(60 mm. or over). 

We cannot assume that where there is 
a high blood-pressure without tangible or- 
ganic lesions we are dealing with arterio- 
sclerosis, as not all cases of arterio- 
sclerosis raise tension, and certain other 
factors have also to be considered as : 

(1) Pain, mental and nervous excite- 



IN GENERAL PEACTICE 63 

ment, etc., mentioned under physiological 
factors (page 40). 

(2) Drugs, e. g., nicotine, which by its 
direct effect on the arterial wall raises ten- 
sion, though where long continued it low- 
ers tension, owing to its toxic action on 
cardiac muscle. 

(3) Such conditions as asphyxia and 
edema. 

(4) In addition there are certain toxic 
conditions of increased internal secretion 
as where the adrenals or pituitary bodies 
are overactive, in which case the tension 
might be high without any sclerotic 
changes being present. 

While the role of primary arterio- 
sclerosis in causing high blood-pressure is 
limited, being associated with hypertension 
in only fifty per cent, of the cases (where 
the generalized sclerosis affects the 
splanchnics or the aorta above the dia- 
phragm), hypertension, no matter what its 
source may be, if continued, causes changes 
in the vessel walls producing marked 
sclerosis and cardiac hypertrophy. 



64 BLOOD PEESSUEE 

Arteriosclerosis as a result of continued 
high, tension of course is accompanied by a 
high blood-pressure, but in arteriosclerosis 
due to the toxine of infection often the 
blood-pressure is normal or if raised it is 
later in the process. Pure senile arterio- 
sclerosis has no associated hypertension. 

Dr. E. D. Eudolph says: "It is safe to 
argue in cases of arteriosclerosis with in- 
creased pressure that the relative differ- 
ence between the systolic and diastolic 
pressures {pulse pressure, auth.) would be 
a measure of the degree to which the in- 
creased pressure was due to the sclerosis 
of the arterial tract between the heart and 
the point at which the pulse is being felt." 

There is no way of diagnosing cerebral 
arterial degeneration absolutely from the 
general blood-pressure, but the probability 
of its presence should be borne in mind 
where there is superficial sclerosis asso- 
ciated with a moderate elevation of blood- 
pressure. 

Sir T. Clifford Albutt, in speaking of 
this subject, lays down the rule that every 



IN GENERAL PRACTICE 65 

individual over forty should have blood- 
pressure taken every four or five years, 
that he may know if there is a tendency 
to arteriosclerosis, the presclerotic stage 
being noted long before the heart is af- 
fected. 

In conclusion, I wish to call attention to 
two important points: (1) That arterio- 
sclerosis is often so closely associated with 
diseases producing high tension, . as ne- 
phritis and cardiac conditions, that the 
hypertension present in such cases is due 
to the associated disease and not to the 
arteriosclerosis. These diseases will be 
considered under their separate heads. 

(2) There is a class of patients who 
have had a high arterial tension, but owing 
to a marked myocarditis and, in some 
cases, cardiac dilatation, resulting from 
the continued high tension, the high sys- 
tolic pressure in the early stages becomes 
about normal in height, or even a little 
lower than normal. These cases are more 
serious than those in which the tension re- 
mains high, as they show that the com- 



66 BLOOD PEESSUEE 

paratively high tension can no longer be 
maintained by the heart. Many serious 
mistakes have been made by considering- 
such cases as in good health because the 
systolic pressure is about the normal level 
or lower. These cases can easily be diag- 
nosed if the diastolic pressure be taken as 
well as the systolic, for, while the heart 
muscle cannot maintain the systolic pres- 
sure, the peripheral resistance in the ves- 
sels, due to the sclerosed condition of their 
walls, remains and maintains a relatively 
high diastolic pressure, giving a small 
pulse pressure. 

The treatment of this condition will be 
considered under hypertension. 

Autointoxication.— Here is often found 
a markedly elevated blood-pressure, but in 
some cases where there is marked consti- 
pation the pressure may be low. 

As Dr. W. H. Sheldon aptly puts it: 
"Headaches and dizziness supposed to be 
due to high pressure I have again and 
again seen disappear with laxatives and 
diet and no change in the blood-pressure. 



IN GENERAL PRACTICE 67 

Most of the cases given above had in- 
creased indican in the urine, and I am in- 
clined to believe that the headaches and 
dizziness are due more to intestinal putre- 
faction than high pressure." 

Diabetes.— In this disease blood-pres- 
sure determinations are of no value from 
either a diagnostic or prognostic stand- 
point, as the disease only affects the height 
of blood-pressure when complicated by 
other conditions, e. g., arteriosclerosis. 
When there is a marked acidosis there is 
a rather marked rise in blood-pressure 
proportionate to the degree of acid intoxi- 
cation. 

Drugs.— Here will be mentioned briefly 
only those drugs which produce hyperten- 
sion, those reducing arterial tension being 
mentioned under the treatment of hyper- 
tension. 

Briggs and Cook, in an extensive series 
of experiments at the Johns Hopkins Hos- 
pital, obtained some very valuable infor- 
mation as to the blood-pressure-raising 
value of drugs, finding : 



68 BLOOD PRESSURE 

Adrenalin, when administered intrave- 
nously, raised the blood-pressure to any 
desired height, but was transitory. 

Cocaine in post-operative low tension 
and in hemorrhage given in doses of *4-% 
a grain, hypodermically, produced an al- 
most immediate rise in blood-pressure of 
10 to 20 mm., which was maintained 1 to 3 
hours. 

Camphor proved generally inert. In 
weakened cardiac systole and in acute toxic 
cardiac dilatation, it produced good results, 
but the same conditions were amply cov- 
ered by strychnia and digitalin. 

Digitalis, when given as digitalin hypo- 
dermatically, was more certain to raise the 
blood-pressure than strychnia, its action 
was manifest earlier, reached a maximum 
sooner, but the action was not so long 
maintained. Given in doses of 1-20 to 1-10 
of a grain hypodermatically, digitalin 
often caused a rise when strychnia failed, 
blood-pressure being maintained by a com- 
bination of the two. 



IN GENERAL PEACTICE 69 

Normal saline solution was found of lit- 
tle value in cases of shock, unless there 
was added 14 to % a grain of cocaine, or 
10 minims of adrenalin to the intravenous 
injection. 

In hemorrhage, when the bleeding point 
had been secured, the saline solution raised 
the blood-pressure, by increasing the vol- 
ume of the blood, and was found very val- 
uable. 

Strychnia in doses of 1-60 to 1-10 of a 
grain raised blood-pressure, and its effect 
was maintained from one to four hours. 
After eight to twelve doses there was no 
further rise, but if one or two doses were 
omitted the pressure fell, but could be 
raised again by renewed administration of 
the drug. "On the whole, strychnia is by 
far the most satisfactory cardiovascular 
stimulant for long continued routine ad- 
ministration. ' ' Doses of 1-20 to 1-10 of a 
grain hypodermatically produced a quick 
response, raising the blood-pressure 80-100 
mm. A dose of 1-20 of a grain often gives 



70 BLOOD PBESSUEE 

a 40-mm. rise, lasting one hour. When the 
pressure begins to fall it may be main- 
tained by a smaller dose. 

Among other drugs which elevate blood- 
pressure are: 

Atropine, increasing both cardiac energy 
and peripheral resistance. 

Pituitary extract ("Vaparole") 1 c. c. 
twice daily gives a marked and sustained 
rise, but causes severe symptoms, and at 
the present writing is not a safe drug to 
use in reduced blood-pressure. 

Caffein, in the form of the citrate, 10 
grains three times a day, is very efficient, 
and is next to pituitary extract in the 
strength of its reaction. Caffein must not 
be used in tea drinkers. 

Tea and coffee both produce a transi- 
tory rise. Subjects who indulge freely 
often have a high tension, which leads to 
arteriosclerosis. 

Ergot produces a slight elevation of 
blood-pressure due to its vasoconstricting 
effect. 

Epilepsy, Idiopathic— It is associated 



IN GENEEAL PEACTICE 71 

with a slow pulse and a high blood-pres- 
sure, which falls with the termination of 
the attack, the fall of the high blood-pres- 
sure being an aid in the differential diag- 
nosis of the post-epileptic state and 
uremia, as in the latter there would be a 
maintained pressure during coma. 

Exophthalmic Goiter. —Blood-pressure 
is variable, but as the disease is often ac- 
companied by a hypertrophied heart, the 
systolic pressure is often raised, e. g., 

Systolic 140-160 mm. Hg 

Diastolic 90-110 mm. Hg 

Pulse pressure 30-50 mm. Hg 

Pulse rate 120 or more 

Eye Diseases.— In diseases of the eye 
high arterial tension plays a very impor- 
tant role, and the determination of blood- 
pressure is very valuable in the diagnosis, 
prognosis, and treatment of many ocular 
conditions. 

The routine determination of blood-pres- 
sure in such cases is imperative, for by 
means of it many cases of high blood-pres- 
sure are discovered and corrective treat- 



72 BLOOD PRESSURE 

ment instituted before any extensive 
ocular changes have taken place. 

It is now well recognized that a high 
arterial tension, if maintained, no matter 
from what exciting cause, will produce 
sclerotic changes in the walls of the ar- 
teries, affecting the general vascular sys- 
tem (see hypertension), and the vascular 
system of the eye being part of the per- 
ipheral circulation is also affected. 

Not only is the determination of high 
blood-pressure in relation to eye diseases 
of importance to the oculist but also to 
the internist and general practitioner, for 
when the general practitioner discovers he 
has a case of high arterial tension he 
should think of the possible conditions 
which might result from such hyperten- 
sion, not only to the general circulation, 
but also to the special organs of the body. 

In many cases by consulting with a com- 
petent oculist at once the patient may be 
saved much damage to the eye by the im- 
mediate adoption of corrective measures. 

The following are the most important 



IN GENERAL PRACTICE 73 

ocular conditions in which, increased blood- 
pressure is significant: 

Spasm of the Retinal Vessels. — There 
are a number of patients with temporary- 
unilateral blindness, sudden in onset, and 
lasting from ten minutes to half an hour. 
Both eyes may be affected, but not at the 
same time. 

In a few of these cases, where the pa- 
tients could be examined during an attack, 
the ophthalmoscope showed a blanching of 
the retinal vessels, due to the arterial 
spasm, disappearing when the attack ter- 
minated. These attacks were invariably 
associated with high arterial tension, and 
under proper treatment directed to the 
lowering and maintenance of a normal 
blood-pressure such cases do well and 
often are prevented from developing ac- 
tual sclerotic changes in the vessel walls. 
Even if treatment is not instituted until 
late in the course of the disease, further 
damage can often be prevented, but the 
important point is to discover the condi- 
tion early, while it is purely an arterial 



74 BLOOD PRESSURE 

spasm without any actual arterial change. 

Untreated, these cases are followed by- 
marked sclerotic vascular changes, and in 
many thrombi and emboli are formed, with 
all their serious and lasting effects. 

Cataract. — In this class of cases there 
are so many sclerotic changes (the catar- 
act being part of a general sclerotic proc- 
ess), high tension is almost universal. 
Most ophthalmologists do not consider that 
the sclerosis present contraindicates cat- 
aract extraction, but these cases often de- 
velop a post-operative intraocular hemor- 
rhage due to the arterial hypertension, 
with resulting blindness. 

By a determination of the blood-pres- 
sure before operation and the institution 
of preparative treatment, i. e., such as 
bleeding, etc., the arterial tension may be 
lowered and subsequent intraocular hem- 
orrhage prevented. A bleeding of from 
eight to sixteen ounces lowers the blood- 
pressure markedly, the amount required 
being determined by the sphygmoma- 
nometer readings, and as the tension re- 



IN GENERAL PRACTICE 75 

mains low for several days, it gives the 
eye time to become accustomed to its new 
condition and intraocular hemorrhage is 
thus prevented. 

Chronic Interstitial Nephritis in Rela- 
tion to the Eye. — This subject is very 
clearly treated by Dr. Luther C. Peter 
when he says: "In chronic interstitial ne- 
phritis more or less direct relation between 
the height of the tension and the severity 
of the symptoms is observed, modifying 
influences being age, degree of arterio- 
sclerosis, the duration of the high tension 
and the individual resisting power. 

"Other things being equal, the amount 
of retinal disease will be in proportion to 
the height and duration of the increased 
tension. 

"Increased blood-pressure is one of the 
earliest premonitory signs of arterio- 
sclerosis and chronic interstitial nephritis, 
and possibly acts as a causative factor, 
and second that arterial hypertension is 
the cause of early retinal and arterial 
changes as well as later phenomena." 



76 BLOOD PEESSURE 

Glaucoma. — Hypertension is now con- 
sidered by the majority of ophthalmologists 
to be the probable causative factor in cases 
of glaucoma. 

Hypertension is invariably present and 
affords a very valuable means of diagnosis 
as also indications as to treatment. 

Retinal Hemorrhage. — Eetinal hemor- 
rhage of non-traumatic origin is due to in- 
creased blood-pressure. 

Dr. Peter, in a review of this subject, 
gives the following summary: 

"Arterial hypertension is the chief 
cause of eye ground phenomena observed 
in chronic interstitial nephritis and ar- 
teriosclerosis. 

"Senile vascular changes, associated 
with high blood-pressure, may be observed 
at times, before these diseases are diag- 
nosed by other clinical symptoms. 

"It frequently acts as a cause for sub- 
conjunctival hemorrhage and is so closely 
associated with glaucoma that it should be 
regarded as an active factor in the devel- 
opment of the disease. 



IN GENERAL PRACTICE 77 

"It probably will help to explain the 
phenomena of intraocular hemorrhage 
after cataract extraction. 

"In order to prevent and to treat ration- 
ally the more serious eye conditions rou- 
tine blood-pressure studies should be made 
in all cases of intraocular disease not 
traumatic. ' ' 

Gout.— Gives increased tension both 
during the attack and between attacks, 
when arterial changes are marked. 

Heart Disease.— This subject will be 
treated under its several divisions as the 
different forms of cardiac disease are 
fairly well defined. Angina pectoris has 
already been treated under a separate 
head so will not be mentioned here. 

Aortic Regurgitation. — Here is found a 
systolic pressure 75 to 100 per cent, higher 
than the diastolic, the pulse pressure be- 
ing very high. In some cases 120 to 130 
mm. systolic, diastolic, 50 to 60 mm., in 
other cases often 170 to 220 mm. systolic, 
diastolic 60 to 140 mm.; but in all cases 
the pulse pressure is great. 



78 BLOOD PRESSURE 

When you auscult over the artery in 
taking the blood-pressure reading you often 
note a continuance of sound (an aid in di- 
agnosing this condition), so that the dias- 
tolic pressure has to be determined by pal- 
pation in severe cases.* 

In well compensated cases sound does 
disappear. 

Dr. Leonard Hill showed that blood- 
pressure is about the same in both brachial 
and femoral arteries, but in aortic regurgi- 
tation the readings from the femoral are 
much higher. 

When the relation of pulse pressure to 
the diastolic reading is low, it is not likely 
that there is aortic insufficiency. 

Chronic Cardiac Hypertrophy. — Here 
we have an increase in both systolic and 
diastolic pressure (systolic 140 to 160 mm., 
diastolic 90 to 110 mm. Hg). 

Cardiac Valve Lesions Other than Aor- 
tic. — Blood-pressure in these cases is normal 
when compensation is good. 

* Now that the time the second thumping sound be- 
comes dull is established as the correct diastolic pressure, 
the minimal pressure (diastolic) can be easily obtained 
by the auscultation method. 



IN GENERAL PRACTICE 79 

Heart with Loss of Compensation and 
Asthma. — Here is found high tension from 
associated asphyxia: when severe, actual 
edema of lungs takes place and life is in 
danger, the blood being loaded with carbon 
dioxide, e. g., bleeding, amyl nitrite, nitro- 
glycerine, and later, after acute condition is 
relieved, cardiac stimulants. 

Myocarditis. — There are many cases of 
myocarditis not discoverable by physical 
examination either because of their slight 
degree or because in fat subjects with 
large chest walls clear physical signs are 
impossible to obtain. It is in these cases 
that blood-pressure helps not only to make 
the diagnosis but also to determine the ex- 
tent of the disease. 

Myocarditis and a good general idea of 
its extent can be determined by means of a 
functional test devised by Graupner. 

Take the pulse rate and the blood-pres- 
sure of the patient to be tested and then 
give a prescribed amount of exercise, as 
walking up a certain number of steps, etc., 
then take the pulse rate and the blood-pres- 



80 BLOOD PRESSURE 

sure every five minutes. A normal heart 
will, during exercise, cause a rise of blood- 
pressure associated with an accelerated 
pulse rate. 

The blood-pressure and the pulse rate 
will remain elevated during the exercise 
unless it is excessive or unduly prolonged. 
With a cessation of the exercise both 
blood-pressure and pulse will, in a short 
time, return to their previous level, the 
pulse rate a little before the blood-pres- 
sure. 

In myocarditis cases, if mild, there will 
be an elevation of blood-pressure and an 
acceleration of the pulse rate, but the 
blood-pressure in a short time will fall 
below or to its previous level, while the 
pulse rate remains high longer. In some 
severe cases the blood-pressure will fall 
from the start, the pulse rate increasing, 
the blood-pressure rising to its previous 
level only after a long time. 

In addition there are myocarditis cases 
of large, weak hearts with dyspnea, edema, 
and subjective symptoms: 



IN GENERAL PEACTICE 81 

(1) With hypertension. 

(2) Without hypertension. 

(1) These are cases secondary to 
Bright 's disease or arteriosclerosis, or are 
primary myocarditis cases which have de- 
veloped Bright 's. 

(2) These are primary uncomplicated 
cases of myocarditis or in the terminal 
stage of the secondary type. 

The primary cases usually show a high 
normal blood-pressure, and are more lia- 
ble to have edema (systolic 135 to 145 mm. 
Hg). 

Acute Endocarditis. — It is associated 
with a low systolic pressure. 

Bradycardia. — Here the pulse pressure 
is increased. 

Cardiac Arrhythmia. — There are many 
cases of arrhythmia purely functional in 
character, but there are also a number 
with true organic disease. It is in these 
doubtful cases that blood-pressure deter- 
minations are of great value. 

In discussing physical diagnosis Dr. 
Eichard C. Cabot says: 



82 BLOOD PRESSURE 

"On the other side are irregular hearts 
which you finally believed to be merely 
functional in origin and to have no imme- 
diate significance, because the blood-pres- 
sure is normal. An irregular heart plus a 
high blood-pressure is serious. The very 
same heart with low blood-pressure may 
be of no significance. ' y 

Dr. Cabot further makes this statement 
about cardiac cases in general: "Patients, 
the examination of whose hearts does not 
show anything certainly characteristic of 
disease, have often been shown to be dis- 
eased, or proven later to be diseased, by 
the high blood-pressure registered by the 
machine, pressure which my fingers are 
not able to detect in feeling the pulse at 
the periphery/' 

Increased Intracranial Tension.— Apo- 
plexy, Depressed Fracture of the Skull, 
Fracture of the Base, Jacksonian Epilepsy, 
Intracranial Hemorrhage, Tumors, {rapid 
growing cerebral). 

In these conditions of increased intra- 
cerebral pressure the highest blood-pres- 
sure readings occur. Hirschfelder gives 



IN GENERAL PRACTICE 83 

Systolic 300-400 mm. 

Diastolic 160 mm. or over 

Pulse slowed. 

The high pressure is compensatory and 
is the effort to supply more blood against 
the increased intracerebral tension and 
thus prevent anemia of the brain. 

The important point is not to bleed, and 
try to lower the pressure, but to operate 
where possible, and where not, to give 
atropine to paralyze the vagus, and to al- 
low the pressure to rise more rapidly. 

In a case of head injury the blood-pres- 
sure reading is of great value ; for in con- 
cussion the pressure is low, whereas in the 
above-named conditions it is invariably 
high, unless very late when cerebral 
paralysis has developed. 

Nephritis. * — In nephritis, especially in 
the chronic forms, blood-pressure deter- 
minations are one of the most valuable 
means of diagnosis. Dr. Richard C. Cabot 

* In cerebral thrombosis the pressure is normal, or at 
least but very slightly elevated, easily distinguishing 
these cases from true apoplexy. In cerebral thrombosis 
symptoms are often relieved and cases cured by giving 
strychnine and stimulants. 



84 BLOOD PRESSURE 

says: "Then calling your attention to the 
early diagnosis of kidney lesions, I see a 
good many cases of renal disease entirely 
free from albuminuria or from casts, but 
with high blood-pressure, which are shown 
later, post mortem, to be renal disease. 
These cases could not have been suspected 
to be renal disease except by blood-pres- 
sure. In other words, I regard the blood- 
pressure measurements as of more impor- 
tance than the examination of the urine in 
chronic kidney trouble. Examination of 
the urine has again and again led me 
astray, the measurement of the blood-pres- 
sure almost never." 

(A) Chronic interstitial nephritis gives 
a high systolic pressure (200 mm. or 
higher), and a relatively low diastolic pres- 
sure; giving a large pulse pressure (60 to 
80 mm. Kg). 

Here hypertension is one of the most 
important signs, often making the diag- 
nosis in obese individuals, where the en- 
largement of the heart is hard to define 
and the urine negative for a long time. 



IN GENERAL PRACTICE 85 

Dr. T. C. Janeway says: " Given a sys- 
tolic pressure of over 200 mm., the diag- 
nosis of contracted kidney must be dis- 
proved by repeated examinations before it 
is abandoned.' ' 

Caution. — If the heart has failed to 
compensate, the pressure may be low, and 
it is here that the pulse pressure will aid 
materially. 

In this condition the pulse pressure is 
lessened. 

The prognosis depends not so much on 
the actual height of the mercurial column 
as on a pressure which is rising or resist- 
ant to treatment. The ultimate danger is 
rupture and apoplexy. 

(B) Chronic Parenchymatous Nephritis. 
— In it the blood-pressure is uncertain, 
often being normal. When there is hyper- 
tension it often aids, but its absence does 
not negate the diagnosis. 

(C) Acute Nephritis. — The pressure 
varies greatly, in typhoid fever and 
pneumonia there being no increase in 
tension. 



86 BLOOD PRESSURE 

In scarlet fever, however, there is a 
sharp, sudden rise, often of 50 mm., and it 
is a valuable aid in the diagnosis. 

(D) Uremia. — Here blood-pressure runs 
parallel with the symptoms, maximum 
pressure being very high, in some cases 
290 mm. Hg. 

Pressure falls with the alleviation of the 
symptoms as a general rule, though it may 
fall before fatal termination, due to fail- 
ure of the heart. 

Obstetrics and Eclampsia, etc.— Most 
authorities agree that at the end of preg- 
nancy there is normally a rise in systolic 
blood-pressure (10-15 mm. Hg) with lit- 
tle change in the diastolic pressure; al- 
though Starling, who reported the results 
of cases over a five-year period, believes 
the blood-pressure remains normal. 

A fact recognized by all authorities is 
that the toxemia of pregnancy in the lat- 
ter months is accompanied by a rising 
blood-pressure, and that it is often present 
some time before any other signs or symp- 
toms. 



IN GENERAL PRACTICE 87 

In pregnancy the following figures have 
been given: 



Normal cases — 

Starling — Systolic pressure 110-120 mm. Hg 

J. C. Hirst — Systolic pressure up to 

seven and one-half months 118 mm. Hg 

Systolic pressure mid. last month.. 124 mm. Hg 



The whole subject is well summarized in 
a paper by Dr. J. C. Hirst, in which he 
says: 

"1. Normal blood-pressure in the non- 
pregnant is 112 mm. 

"2. Normal blood-pressure in the 
healthy pregnant is 118 mm. In the last 
month slightly higher. 

"3. Blood-pressure in toxemia in the 
first half of pregnancy associated with 
pernicious vomiting is invariably low. 

"4. Blood-pressure in the toxemias in 
the latter half of pregnancy associated 
with albuminuria and eclampsia invaria- 
bly high. 

"5. High and rising blood-pressure is an 
invariable and early, often the earliest, 



88 BLOOD PEESSURE 

sign of toxemia in the latter half of preg- 
nancy. 

"6. Upon rupture of the membranes 
there is an immediate fall of pressure 60- 
90 mm. This fall is temporary only, but 
is attended with marked relief in the head- 
ache and epigastric pain these patients so 
often complain of. 

"Relief lasts for some hours during 
which there is a gradual return to the pre- 
vious level. 

"7. There is a second fall, 60-90 mm., 
after the child is born. This again is tem- 
porary, and is 15-30 mm.; if the patient 
has not bled profusely, then the pressure 
is back to somewhere near the previous 
level before birth. 

"8. Usually blood-pressure is high for 
48 hours after birth, then begins to subside 
and reaches normal, 118-124 mm., in seven 
to ten days. 

"9. A blood-pressure below 125 mm. 
should be disregarded; 125-150 mm. needs 
careful watching and moderate eliminative 
treatment. 



IN GENERAL PRACTICE 89 

"Over 150 mm. needs active eliminative 
treatment, and probably will, especially if 
there is a tendency to climb higher, require 
induction of premature labor.' ' 

Starling, in treatment, advocates before 
using more drastic methods: Rest in bed 
on a carbohydrate and milk diet, with one 
teaspoonful of bicarbonate of soda four 
times a day, with four pints of liquid and 
thyroid extract in sthenic cases. 

The blood-pressure remains high after 
delivery and the relief of toxemic symp- 
toms, whenever there has been a previous 
nephritis. Hypotension also is important 
after delivery, in relation to the question 
of hemorrhage and shock, being markedly 
lowered in both conditions. This is espe- 
cially important in relation to treatment. 
The question of whether the pressure is 
stationary, progressively rising or falling, 
and its relation to treatment are of more 
importance than absolute figures, though 
the latter serve as a good guide. 

Plumbism.— Both acute and chronic 
cases show a well-marked high tension. 



90 BLOOD PRESSURE 

In doubtful cases, where there is high 
tension, examine for signs of plumbisni. 

Treatment of Hypertension.— Hyperten- 
sion is a symptom and not a disease, and 
its treatment, like that of any other symp- 
tom, is that directed to the cause. At the 
outset it should be clearly borne in mind 
that in a large number of cases hyperten- 
sion is a necessary compensatory process 
in order to maintain a correct cardiovas- 
cular equilibrium. This is especially true 
in advanced cases where marked vascular 
changes have taken place and the condition 
is beyond the spastic stage. Where the 
causation of hypertension cannot be re- 
moved we often, instead of lowering blood- 
pressure, best conserve the interests of 
our patients by maintaining the ten- 
sion. 

Prophylaxis.— Prophylaxis is most im- 
portant and will become more and more 
frequently used as the routine taking of 
blood-pressure becomes more prevalent. 

Many cases of hypertension will be 
found before there are any symptoms at- 



IN GENERAL PRACTICE 91 

tributable to it or any organic changes in 
the blood-vascular system. In other 
words, it will be discovered in the spastic 
stage. 

Dr. L. Gr. Visscher, in a paper on the 
treatment of chronic hypertension, gives a 
very good presentation of this subject. He 
says in substance : 

We should warn our patients against a 
chronic overindulgence in food, more espe- 
cially in food having a large nuclein con- 
tent which tends to form excessive purin 
compounds, which are marked elevators of 
blood-pressure, e. g., meats, kidneys, liver, 
sweet-breads, caviar, cured meat, sausage, 
gravies, old cheese broth, mushrooms, 
peas, veal, etc. 

Equally important is to emphasize 
proper mastication and slow eating; the 
avoidance of excessive muscular exercise, 
without gradual training, but the impor- 
tance of moderate exercise in the open air ; 
the avoidance of late hours without the 
proper amount of sleep, and the overindul- 
gence in coffee, tea, tobacco, and alcohol; 



92 BLOOD PRESSURE 

the value of water drinking ; and the elimi- 
nation of excessive mental work and worry 
and the abstinence from exciting and 
highly stimulating amusements. 

Now, turning to the treatment of a pa- 
tient who comes to us with symptoms of 
hypertension, or one in whom we discover 
the condition during routine examination, 
certain factors are of great importance in 
determining the treatment to be given: 

1. Age of the patient. Those around 
forty years are treated quite differently 
from those of sixty. 

2. Is the hypertension part of an acute 
process or a chronic one? If chronic, how 
extensive are the sclerotic changes? 

3. Is the blood-pressure sufficiently high 
to cause immediate danger of apoplexy or 
cardiac dilatation? 

4. "What is the condition of the myocar- 
dium? 

5. Is the hypertension primary or sec- 
ondary? 

All these questions cannot be answered 
at once, and some can only be determined 



IN GENERAL PRACTICE 93 

after long study, but there are certain lines 
of treatment which we can institute at 
once, which aid us in a diagnosis and at 
the same time benefit our patient. 

Here I shall again quote in substance 
from Dr. L. Gr. Visscher : 

Our first task is to determine the food 
intake of our patient and limit it as to 
quantity, but more especially as to the 
nuclein foods mentioned under prophy- 
laxis, for the formation of purin com- 
pounds produces marked hypertension. 
Here it is important to estimate the in- 
dican, urea, and acidity of the urine in 
order to determine the proteid tolerance 
of these cases. An excessive nuclein food 
causes an acidosis and the carbonic acid 
is retained in the blood and not given off 
so freely from the lungs. As carbonic acid 
has marked pressor effects, the tension is 
elevated. By cutting down nuclein foods 
to their point of tolerance and giving 
plenty of vegetables and fruit the acidosis 
is prevented and the tension lowered. 
Care must be used in old subjects as they 



94 BLOOD PRESSURE 

are accustomed to and need a higher pro- 
teid food; dieting in these cases often 
causes cardiac weakness and severe symp- 
toms. 

As Dr. Visscher says: 

1 ' One routine way is the administration 
of alkaline laxatives, since it has been 
demonstrated that alkalinity of the intes- 
tinal contents increases putrefaction and 
since the products of this process have 
high pressor qualities, it is better to give 
non-alkaline laxatives, when indican is 
abundant in the urine. 

"I have found it of distinct benefit in 
cases in which introduction by mouth of 
alkali increases flatulency to administer it 
by rectum once or twice a day. 

"A frequent coeffect of laxative medica- 
tion is the hurrying of albumoses into the 
realm of the colon bacillus, which thrives 
on albumoses and does not subsist on pep- 
tones ; therefore it is our task to give laxa- 
tives early before breakfast or well after 
the height of digestion. 

"Next it is important to determine 



IN GENERAL PRACTICE 95 

whether we are dealing with a case of 
hypertension with increased intraabdom- 
inal tension. This condition is clinically 
manifested by: Slight dyspnea, moderate 
hypertension, aching limbs, torpid liver 
and catarrhal gastritis.' 9 

The causes are: 

"Abundant food. 

"Gorged liver. 

1 ' Chronic loading of a distended colon. 

"Gas in the stomach and colon. 

"Omental fat." 

These conditions he treats by regulation 
of the diet, use of laxatives in the morn- 
ing, warm enema in the evening, carmina- 
tives and massage of the abdomen. 

"In dealing with general obesity or 
more local embonpoint, a good deal of cau- 
tion is needed; not so much at the disap- 
pearance of fat do we aim as at the timely 
prevention of its formation. When the 
abdominal parietes have first been com- 
fortably filled for years, and thereafter 
uncomfortably stretched for some more 
years, the intra-abdominal circulation 



96 BLOOD PRESSURE 

adapting itself more or less to it in the 
meanwhile, what will happen by energetic 
under-dieting and massaging? Though 
the diaphragm will be greatly freed in its 
excursions, the flabby abdominal wall will 
give insufficient support and a tendency to 
allow intra-abdominal pressure will be 
manifest with a hindrance to expiratory 
excursion. This low intra-abdominal ten- 
sion, accompanied by a feeling of exhaus- 
tion and early fatigue in our advanced hy- 
perpietics, is a far more difficult matter to 
deal with. The inferior cava output is re- 
tarded and the venous splanchnic area re- 
mains gorged, with flatulence and indiges- 
tion as a result, only compensated for by a 
rise of pressure in the splanchnic arteries, 
thereby throwing back the work on the al- 
ready overburdened heart. So, in a meas- 
ure, we should endeavor, in spite of 
hypertension, to overfeed our lean pa- 
tients, not forgetting that many thin peo- 
ple, when hyperpietic. are often big eaters 
and mysteriously powerful alcohol ab- 
sorbers.' ' 



IN GENERAL PEACTICE 97 

Then taking up exercise, bathing, and 
sleep, he says: 

"Within bounds of reason an ample 
amount of outdoor exercise is beneficial. I 
emphasize a one or two-mile constitu- 
tional before retiring, depending on the 
heart's tonicity and reserve force. 

"Warm bathing is very beneficial, both 
morning and evening, with a cold sponge 
or shower thereafter. 

"As to hours of sleep, it should be bet- 
ter understood that carbonic acid is of high 
pressor power, that sleep in ill-ventilated 
rooms will interfere with metabolism dur- 
ing one-third of our lifetime, a time addi- 
tionally spent in the digestion and assimi- 
lation of the heaviest meal of the day. 
Invariably, for reasons already given, peo- 
ple with hypertension would better eat 
light evening meals, with ease thereafter 
for a few hours, then take a moderate 
amount of physical exercise, a warm bath, 
perhaps a warm enema, and sleep in a 
warm bed with the windows wide open." 
If having tried the methods just mentioned 



98 BLOOD PRESSURE 

the desired result is not obtained we may 
then turn to various modes of treatment, 
as drugs, etc. 

The benefit to be derived is in propor- 
tion to the amount of vascular spasm pres- 
ent, it being remembered that even in 
markedly sclerotic cases there is usually 
some arterial spasm present. 

The first to be mentioned are the iodides. 
Dr. J. Mackenzie states that nitrites are 
of little avail, as their action is too transi- 
tory. In cases of high tension with dis- 
comfort, as pain and tightness across the 
chest, he uses potassium iodide in five- 
grain doses four times a day, and finds 
that it often relieves the symptoms, but 
quite often does not lower the tension, 
though marked benefit is shown. (One 
point is to be borne in mind, careful ob- 
servation of the patient to see that he does 
not develop thyroidism from the iodine 
given.) 

Dr. Mackenzie also advocates chloral 
hydrate given in five-grain doses two to 
three times a day, as well as in larger 



IN GENERAL PRACTICE 99 

doses to produce sleep. This is especially 
beneficial in cases of angina pectoris. 

When there is a marked arterioscler- 
osis very little can be done to reduce ten- 
sion ; the only means that would produce a 
marked effect is by bleeding the patient, 
but the result would be temporary, called 
for only when there was danger of apo- 
plexy or dilatation of the heart. Many of 
these cases, however, can be much bene- 
fited by proper hygiene to eliminate what 
spastic condition is still present and 
further can be made comfortable by small 
doses of the iodides. The iodides are of 
especial value in sclerotic cases due to 
syphilis. 

Cases of psychic hypertension from 
mental work and worry, in addition to the 
regulation of diet, exercise, etc., are often 
greatly benefited if put on fairly large 
doses of bromides for a week or so and 
also if given chloral, medinal, veronal, etc., 
to produce sleep. In addition a twenty- 
minute rest after meals will be found very 
beneficial. 



100 BLOOD PRESSURE 

In senile hearts with hypertension it is 
of great value to give digitalis, combined 
with a nitrite or iodide, as in these cases 
the high tension is the result of a venous 
stasis and a better action of the heart re- 
lieves the symptoms and lowers the ten- 
sion. 

In very marked cases of hypertension 
sometimes the use of absolute rest, mas- 
sage and a milk diet will produce a good 
result; in many a reduction in pressure 
may be very rapidly attained by the use of 
an exclusive cereal diet (cooked cereals), 
farina, cream of wheat, grits, rice, etc., es- 
pecially where there is much intestinal fer- 
mentation and an acidosis present. 

Here it might be well to mention the fact 
that in some cases it is beneficial to limit 
the amount of the salt intake as sodium 
chloride causes vasomotor spasm and is 
hard to eliminate. 

In the toxic group of cases active pur- 
gation with blue mass or calomel and the 
use of hot-air baths are most effective. 

Acute toxic cases associated with dila- 



IN GENERAL PRACTICE 101 

tation of the heart are best treated by 
venesection, the amount being determined 
by the sphygmomanometer readings. 

In the hypertension of the toxemia of 
pregnancy aconite in two-drop doses is 
often efficient and does not harm the 
heart, but should not be used in other 
conditions (for further treatment see Ob- 
stetrics). 

Aside from the use of general measures 
given above, Sir Lauder Brunton advo- 
cates the use of blue mass or calomel rou- 
tinely twice a week or even on alternate 
nights, followed by a saline in the morn- 
ing, and also advises patients to carry 
nitroglycerine tablets with them, and 
should any pain in the chest develop take 
them at once. He also gives small 
doses of potassium iodide where sclerotic 
changes are evident in the peripheral ves- 
sels. 

When these means of treatment have 
failed and there are signs of beginning 
cerebral trouble it is necessary to use the 
vasodilators or bleed. 



102 BLOOD PRESSURE 

Dr. R. D. Rudolph gives the following 
as to the vasodilators : 

Nitroglycerine, dose of 1-100 of a grain 
(action lasts an hour, tolerance soon 
formed). 

Sodium nitrite, dose of 2 grains (action 
lasts two hours, no tolerance acquired). 

Erythrol tetra-nitrate, dose y 2 grain 
(action lasts 6 hours, tolerance acquired). 

While tolerance may not be acquired in 
many cases from sodium nitrite or ery- 
throl tetra-nitrate, in many others there 
are very unpleasant symptoms and a 
marked tolerance develops. 

The benefit to be derived from vaso- 
dilatation and rapid reduction of hyper- 
tension in those cases it benefits can be 
understood well by the evidence brought 
out by Dr. Charles H. Lawrence. 

"Reduction of systolic pressure in cases 
of hypertension by nitrites, venesection, 
electricity, or hot air, is accompanied by 
a fall in diastolic pressure amounting, as a 
rule, to approximately one-half the systolic 
fall. Such a reduction produces a coef- 



IN GENERAL PRACTICE 103 

ficient of pressure more nearly approxi- 
mating the normal than does the coefficient 
under the condition of hypertension. 

"None of the nitrite group are efficient 
for maintaining a pressure at a perma- 
nently lowered level, as a tolerance is soon 
acquired and increasing the dose is apt to 
cause unpleasant symptoms." 

We may also use thyroid extract in two- 
grain doses, three times daily. 

In addition to drugs, certain mechan- 
ical, electrical, and hydrotherapeutic 
modes of treatment are sometimes of value, 
although uncertain, and their effects tran- 
sitory, as a rule, e. g., 

High frequency by means of the D'Ar- 
sonval current. 

Electric light baths are often valuable, 
stimulating circulation and increasing 
metabolism, and thus eliminating much 
waste. 

Oxygen baths produce a sedative action 
and markedly lower tension, being of value 
in cases of psychic hypertension (tempera- 
ture 97 deg. F.). 



104 BLOOD PRESSURE 

Wet pack is often of value in high blood- 
pressure in neurasthenia associated with 
insomnia (temperature of 70 deg. F.). 

In addition we have massage, Swedish 
gymnastics, and vibrassage. 



IN GENERAL PRACTICE 105 



CHAPTER VI 

HYPOTENSION 

BY HYPOTENSION is meant a sys- 
tolic blood-pressure of one hundred 
millimeters or lower. Here are in- 
cluded a large number of cases of asthenia, 
etc., but there are also a large number of 
persons in whom the hypotension is the re- 
sult of acute infections and conditions of 
sudden onset, in whom the tension is low 
due to vasomotor depression. 

In blood-pressure determinations the im- 
portance of hypertension has been allowed 
to outweigh the value and significance of 
hypotension, so that in many cases no at- 
tention has been paid to a condition that in 
many cases is very important and of great 
significance in diagnosis, prognosis, and 
treatment. 
In the majority of cases the low pres- 



106 BLOOD PRESSURE 

sure is due more often to the depression of 
the vasomotor center by toxines than to 
cardiac weakness, though there is usually 
some associated cardiac involvement. 

The various diseases accompanied by 
hypotension will be considered in alpha- 
betical order, and where their treatment is 
not given under their individual heads it 
will be taken up under the general treat- 
ment of hypotension. 

Acute Cardiac Conditions and Pericar- 
ditis.— -Here pressure is low, the vaso- 
motor center being depressed by the tox- 
ines of the disease, and there is also some 
weakness of the heart muscle. The sys- 
tolic pressure varies from 98 to 140 
mm. 

Chronic Wasting Diseases.— Cancer, 
Chronic Phthisis, Anemias, etc. 

There being associated brown atrophy 
of the heart, as a consequence there is low 
blood-pressure in all these conditions. 

Systolic, 10-20 mm. lower than normal. 

Diseases with a Marked Loss of Fluid. 
— Cholera, diarrhea, dysentery, and after 



IN GENERAL PRACTICE 107 

profuse vomiting, as in carcinoma of the 
stomach, intestinal obstruction, and peri- 
tonitis. 

In these conditions there is a markedly 
lowered blood-pressure due to a large ex- 
tent to the loss of fluid diminishing the 
volume of the circulating blood. Blood- 
pressure determinations are of great value 
in deciding as to the extent of the condi- 
tion, as to the kind of treatment to be em- 
ployed, and its efficacy. Lowering blood- 
pressure is an indication of impending col- 
lapse. 

Drugs. — Alcohol. — In small amounts 
there is but little effect on blood-pressure, 
but in any quantity there is a vasodilata- 
tion with hypotension. Long-continued use 
leads to sclerotic changes and higher ten- 
sion. 

Tobacco. — Its moderate or occasional 
use produces a slight rise. When used to 
excess it produces low tension, due to the 
toxines in the tobacco. 

When tension is low from tobacco all to- 
bacco must be discontinued, as a small 



108 BLOOD PEESSUEE 

quantity will continue the low tension after 
it is once established. 

Other drugs which lower blood-pressure 
are : Aconite, the nitrites, the iodides, the 
laxatives and purgatives, chloral hydrate, 
pituitary extract, and thyroid extract (see 
treatment of hypertension). Chloroform 
also lowers tension (see surgery and anes- 
thesia). 

Hemorrhage, Extensive.— In these cases 
there is a marked drop in blood-pressure 
proportionate to the amount of the hem- 
orrhage, being a mechanical result due to 
the lessened volume of the blood the heart 
has to pump. This fall in pressure is fol- 
lowed by a rather rapid rise to the normal 
level as soon as the bleeding point is se- 
cured. After securing the bleeding point 
the pressure is best restored by an intra- 
venous injection of saline. 

Acute Infectious Diseases.— In all in- 
fectious diseases, except meningitis, there 
is a fall in blood-pressure, due mainly to 
vasomotor depression or paralysis, from 
the toxines present, but also to a lesser de- 



IN GENERAL PRACTICE 109 

gree to the damaged heart muscle, from 
the same cause. 

The systolic pressure usually falls be- 
low one hundred millimeters of mercury, 
and remains low during the acute process 
of the disease, and in some cases late in 
the convalescence. 

The acute infectious diseases in which 
blood-pressure has a special significance 
will now be considered in alphabetical 
order. 

Diphtheria. — As might be expected in a 
disease marked by such severe toxemia the 
blood-pressure is often very low. Blood- 
pressure values aid materially in deciding 
what stimulation, if any, is required, and 
are of great value in determining the con- 
dition of the myocardium during convales- 
cence and deciding when to allow any 
physical exertion. In a condition where 
the danger of cardiac failure is so great 
any accurate means of determining the ex- 
act condition present is of inestimable 
value. 

Pneumonia. — Here there may not be 



110 BLOOD PRESSURE 

much change in the blood-pressure, though, 
as the disease progresses, there is a ten- 
dency for it to lower. 

Hirschf elder— Systolic 110-130 mm. Hg 

Diastolic 90-130 mm. Hg. 

Pulse rate 120 

Gibson of Edinburgh made a general 
rule which seems to work out well in pa- 
tients who are not alcoholics, but does not 
apply to this class of patients. The rule is 
as follows : When the systolic pressure ex- 
pressed in mm. of Hg is higher than the 
pulse rate expressed in beats per minute, 
the condition of the patient is good. When 
the systolic pressure expressed in mm. Hg 
is lower than the pulse rate per minute, the 
condition is serious. 

Dr. Alexander Lambert, in a recent ar- 
ticle, called attention to the fact that the 
blood-pressure varies greatly in pneu- 
monia, but that it is of the greatest value 
in determining whether the condition pres- 
ent is one of vasomotor paralysis, due to 
toxines, in which case the blood-pressure 



IN GENERAL PEACTICE 111 

will be found to be low ; or whether the pa- 
tient is suffering from high tension, with 
cardiac failure imminent. 

About one-half the cases die of vaso- 
motor paralysis, the other half from fail- 
ure of the heart. In the one, adrenalin, 
camphor, strychnia, and digitalis are in- 
dicated; in the other> relief of the high 
tension with vasodilators or bleeding is in- 
dicated. 

The matter is very tersely expressed by 
Dr. H. A. Hare when he says : 

"If the vessels be at fault the difference 
between diastolic and systolic pressure 
will be marked, the heart, if strong, send- 
ing out a forcible wave of blood in an en- 
deavor to fill the blood paths. On the 
other hand, if the pressure be low from a 
failing heart, there will be little difference 
between diastolic and systolic pressure, 
for obvious reasons.' ' 

The blood-pressure is important not only 
in the beginning for diagnostic purposes, 
but also throughout the course of the dis- 
ease in order to determine the treatment 



112 BLOOD PRESSURE 

required, and, if drugs are indicated, to 
regulate their dosage and the duration of 
their use. 

Rheumatism, Acute Articular. — Here 
the blood-pressure is also low and the 
readings are of main importance in de- 
termining the treatment and progress of 
the case during convalescence. 

Scarlet Fever. — Hypotension is present 
in the ordinary uncomplicated case, but 
should nephritis develop during the course 
of the disease there is a sharp, marked rise 
in tension. This does not take place in 
other infectious diseases. 

Typhoid Fever. — Here we have one of 
the lowest pressures occurring in diseases. 

Often systolic 100-120 mm. Hg 

diastolic 60-90 mm. Hg 

The systolic pressure has been as low as 
75 mm. Hg. 

The fall in pressure is gradual, and 
takes place progressively (Janeway), e. g. 



IN GENERAL PRACTICE 113 

First week — Systolic 115 mm. Hg 

Second week — Systolic 106 mm. Hg 

Third week — Systolic 102 mm. Hg 

Fourth week — Systolic 98 mm. Hg 

Fifth week— Systolic 96 mm. Hg 

Here the value of routine blood-pressure 
observations is very great, both to deter- 
mine the effect and amount of treatment 
required, and also to be able to note the 
onset of complications. 

In hemorrhage there is a sharp sudden 
fall, due to a lessened volume of blood. 

In perforation just the opposite takes 
place, the irritation of the peritoneum 
causing a reflex vasoconstriction and a 
sudden sharp rise in blood-pressure. 

The work of Briggs and Cook showed in 
one case a rise of blood-pressure hours 
before there were any other definite signs 
of perforation. The diagnosis was con- 
firmed by operation. But as they demon- 
strated, you do not always obtain a rise 
in blood-pressure, for the vasomotor center 
may be exhausted, in which case there will 
be no rise. Therefore, a lack of rise in 
blood-pressure does not negate other signs, 



114 BLOOD PRESSURE 

and symptoms of perforation, but when 
high pressure is present it is reliable, un- 
less pneumonia develops. 

Using blood-pressure in conjunction 
with treatment they find : 

Baths when favorable produced a rise in 
blood-pressure. 

Of the drugs, strychnia and digitalis 
were the best to combat collapse. When 
used for a quick result strychnia, gr. 1-10- 
1-20 hypo., was given, and the resulting 
rise in blood-pressure was maintained for 
an hour or so. When the pressure begins 
to fall, it may be maintained by a smaller 
dose. 

Digitalin hypo, was more certain than 
strychnia, with an initial dose of gr. 1-10 ; 
its action taking place earlier, though not 
so long continued. It often gave a rise 
when strychnia failed. Permanency of 
results may be obtained by combining the 
two. 

Alcohol was of no value as a stimulant, 
but lowered pressure, and was of benefit 
solely as an alternative. 



IN GENERAL PEACTICE 115 

Thayer found, as a sequence of typhoid 
fever, a rather marked hypertension some 
years after the original attack. 

Acute Infections of Children.— Here 
Briggs and Cook found blood-pressure de- 
terminations of the greatest value in prog- 
nosis and treatment. If pressure is fall- 
ing there is danger of collapse, and it is an 
indication for active stimulation. 

They concluded that a systolic pressure 
of 60 mm. during the first year, and 80 mm. 
in older children, were the danger lines, 
calling for active stimulation. 

Treatment. — In collapse with cyanosis 
they used a mustard bath, and found that 
strychnia and digitalis were the most re- 
liable drugs. 

Prognosis. — A short-lived response to 
treatment with a renewed fall is a bad 
sign. 

Neurological Conditions.— (a) Alco- 
holic Delirium. — Here pressure is lowered 
30-40 per cent., therefore we must use care 
in the employment of hot packs to quiet 
these patients, as we may cause collapse. 



116 BLOOD PRESSURE 

(b) Insomnia may be associated with 
either one of two conditions : 

1. High tension (systolic, 130-150 mm.). 

2. Without high tension. 

In the first vasodilators act as hypnotics 
and are indicated ; sleep takes place as the 
pressure falls. 

In the second class sulphonal, trional, 
and similar drugs are more effec- 
tive. 

(c) Acute Mania. — Here blood-pressure 
is low, and after an attack lower still, due 
to exhaustion. 

(d) Melancholia elevates blood-pres- 
sure in proportion to the symptoms, and is 
relieved by vasodilators, improvement oc- 
curring coincidently with the lowering of 
pressure. 

(e) Neurasthenia, Hysteria, etc. — Pres- 
sure here is variable, but becomes high 
readily, owing to the nervous stimulation 
of the vasomotor center. 

(f ) General Paresis. — Here in the early 
stage blood-pressure is normal, while in 
the late it is low. 



IN GENERAL PRACTICE 117 

(g) Trifacial neuralgia is accompanied 
by a high blood-pressure. 

Phthisis.— Here we usually find a low 
systolic pressure; systolic, 90-100 mm., 
though it may vary between 80 and 120 
mm. 

Blood-pressure from the standpoint of 
prognosis and treatment is of considerable 
value, though, as to diagnosis, there is a 
marked difference of opinion, many think- 
ing it of doubtful value before physical 
signs have developed. 

Given a patient with tuberculosis a fall- 
ing blood-pressure is a bad sign, while a 
rising blood-pressure toward the normal is 
equally favorable. 

When the blood-pressure has reached 
the normal, and remained there, we may 
feel pretty confident our case is well; so 
that in supposedly cured cases it is impor- 
tant to take the blood-pressure observa- 
tions to determine whether there is any re- 
currence of the disease. 

Given a patient with a persistent low 
blood-pressure, always consider the proba- 



118 BLOOD PRESSURE 

bility of tuberculosis very seriously, espe- 
cially where other causes for the low ten- 
sion cannot be determined. 

Lauder Brunton regards low tension as 
due usually to : 

1. Beginning phthisis. 

2. Excessive smoking; further stating 
that where smoking can be excluded, al- 
ways examine the lungs carefully for tu- 
berculosis. 

Dr. Haven Emerson warns us that per- 
sistent low tension should put us on our 
guard to prevent tuberculosis, especially 
where the patient is under unhygienic con- 
ditions. (See Altitude for effect in 
Phthisis.) 

Shock and Collapse.— Here we have a 
very marked and dangerous fall in blood- 
pressure, due to vasodilatation, from per- 
ipheral nerve stimuli to the vasomotor 
center. Henderson claims the vasomotor 
depression is due to overaeration, and lack 
of carbon dioxide to stimulate the center. 
At times the systolic pressure has been as 
low as 40-60 mm. 



IN GENERAL PRACTICE 119 

Cook and Briggs proved that the vaso- 
motor center was not exhausted, for, by 
the use of strychnia and digitalis, they 
were often able to save apparently hope- 
less cases; that adrenalin intravenously 
will raise the pressure, but that its action 
is fugacious; that an intravenous saline 
injection is of no value to raise pressure 
unless adrenalin is added; and that y± to 
y 2 gr. of cocaine hypo, will give an almost 
immediate rise of blood-pressure (10-20 
mm.) and maintained from one to three 
hours. 

Syphilis.— -There is a hypotension dur- 
ing the acute stages due to the toxemia of 
the disease. 

Tabes Dorsalis.— Pal concluded that, 
with the lightning pains, there was a 
marked fall in blood-pressure; in contra- 
distinction to gastric crises, where there 
was an enormous rise. He assumed that 
as there was marked hypertension the 
splanchnics must be involved, and advised 
the use of chloral to relieve the condition 



120 BLOOD PRESSURE 

on account of its blood-pressure-lowering 
qualities. 

The association of high tension with 
gastric crises aids somewhat in a differen- 
tial diagnosis, as there are only two other 
conditions of pain in the abdomen with 
high tension: (1) lead colic, (2) angina 
abdominalis of arteriosclerosis. 

Treatment of Hypotension. — (1) Gen- 
eral hygiene and tonics. 

2. Hydrotherapy is of some value, e. g., 
Needle bath, graduated from warm to cold. 
Vischy bath. 

3. Massage. 

4. Exercise when moderate and grad- 
uated to the needs of the individual. 

5. Laxatives are of benefit where low 
tension is associated with constipation. 

6. Especially valuable in many cases are 
increasing doses of tincture of nux vomica 
until the physiologic limit is reached. 

7. Pituitrin has also been given by 
mouth, 2 grain doses four times a day, with 
marked benefit. 



IN GENERAL PRACTICE 121 



CHAPTER VII 

SURGERY AND ANESTHESIA 

SURGERY AND ANESTHESIA. - 
Anesthesia.— Ether increases the 
blood-pressure first reflexly from the 
irritation of the mucous membrane. Dur- 
ing the second stage the pressure also 
rises, owing to the muscular activity. 

In deep anesthesia the pressure level 
falls to just above the normal. 

Nitrous Oxide. — Here there is a rise of 
pressure due partly to asphyxia. When 
used with ether there is an initial rise, but 
the second increase of pressure is elimi- 
nated, because the stage of muscular ac- 
tivity is avoided. 

Chloroform.-^ Blood-pressure falls from 
the start, and remains low, except in preg- 
nancy. 



122 BLOOD PRESSURE 

If, during anesthesia, shock or collapse 
is imminent there is a marked falling 
blood-pressure, before other signs are 
manifest ; hence the value of taking blood- 
pressure readings every five minutes dur- 
ing the administration of an anesthetic. 
If pressure falls correct any faulty admin- 
istration of anesthetic, and, if the pressure 
then rises, proceed. If the pressure con- 
tinues to fall, or remains at a dangerous 
level, use active measures, and terminate 
operative procedure as rapidly as pos- 
sible. There is less shock by continuing 
the ether than to allow the patient to come 
out, and renew the anesthetic. With a 
dangerous fall in blood-pressure while, 
using chloroform, withdraw the anesthetic 
at once. 

Spinal Anesthesia {cocaine). — You may 
have a dangerous fall due to paralysis of 
the upper dorsal region. 

Operative Procedure. — Cutting or ma- 
nipulative procedures cause a transitory 
rise in blood-pressure of about 10 mm. due 
to the pain impulses conveyed to the vaso- 



IN GENERAL PRACTICE 123 

motor center; it may rise again, remain 
low, or fall further to shock. If cocaine is 
injected into the nerve trunks during an- 
esthesia there is less danger of shock. 

By blood-pressure determinations we 
have the most accurate means not only of 
determining shock, but also its extent and 
reaction to treatment. The blood-pressure 
readings should be taken routinely, not 
only during the operation, but also before 
and after. Before operation often a case 
has a high tension, which might become 
dangerous if an anesthetic were adminis- 
tered, unless it is lowered by preparatory 
treatment. After operation routine ob- 
servations are of value in determining the 
onset of shock or hemorrhage. 

In addition, in pleural and peritoneal ef- 
fusions, there is a rise of blood-pressure. 
Aspiration produces a fall, which can be 
determined by blood-pressure examina- 
tions and the aspiration stopped if the fall 
becomes dangerous. 

In a recent article, "Estimation of Vital 
Resistance of Patient with Reference to 



124 BLOOD PRESSURE 

Possibility of Recovery, " Dr. Joseph C. 
Bloodgood says : 

"For the estimation of the factors of 
safety during operation and the condition 
of the patient directly after operation, it 
is my opinion that the blood-pressure ap- 
paratus is the most important. 

6 ' In the last year I have attempted to re- 
cord blood-pressure measurements before, 
after, and during all operations, with the 
result that I have found these records the 
most important method of estimating the 
exact condition of the patient.' ' 

Under treatment during operation he 
says: 

"During the last year I have paid con- 
siderable attention to the routine blood- 
pressure records, and at the present time 
I am getting the impression that the blood- 
pressure will warn the surgeon of the dan- 
ger line before the pulse or respiration. 
My respect for the blood-pressure record 
is increasing daily, and I would urge all 
surgeons to use it in extraordinary opera- 
tions and handicapped patients. But to 



IN GENERAL PRACTICE 125 

learn to interpret these records, one must 
employ them at all operations as a rou- 
tine. 

"When the blood-pressure falls to 100 or 
lower, it is time to stop the operation and 
time to give the saline, which in such cases 
should be given immediately. I have had 
a few such cases with very happy results. 

1 1 There is one point I wish to make clear 
which many surgeons do not seem to be fa- 
miliar with. The patient seems in fair 
condition at the end of the operation, but 
no blood-pressure record is taken. He is 
lifted to the stretcher, carried to his room, 
and when put to bed is found to be in col- 
lapse requiring hurried treatment. This 
can be avoided in most cases if, after the 
operation is finished and the bandage ad- 
justed, a blood-pressure record is taken. 
If the record is much lower than that 
taken at the end of the operation, it is an 
indication that the patient should not be 
transported, but kept quietly on the table 
and given the salt solution by one or all 
three methods. It is important therefore 



126 BLOOD PRESSURE 

carefully to investigate the patient before 
he is lifted from the -operating table to be 
transported, and to begin the post-opera- 
tive saline treatment then if indicated. I 
am confident that this will prevent many 
of the cases of collapse or sudden vaso- 
motor failure which are observed after the 
patient reaches his bed. 

1 i The surgeon must be familiar with the 
manipulations which produce shock. Noth- 
ing helps him more to estimate this than 
the blood-pressure. It is to be remem- 
bered that anything that either diminishes 
or increases the blood-pressure is a stimu- 
lation which sooner or later will lead to 
exhaustion and a fall in blood-pressure. 
It is the uniform rate of the pulse and 
respiration and uniform blood-pressure 
that indicate an operation with the least 
degree of shock." 



IN GENERAL PRACTICE 127 



CHAPTER Vm 

LIFE INSURANCE 

IN LIFE-INSURANCE examination, 
almost all companies now recognize 
blood-pressure estimation as a neces- 
sary procedure. The reason for this is 
very clearly shown in the statistics from 
the Northwestern Life Insurance Com- 
pany, which was one of the pioneers in tak- 
ing blood-pressure readings on its appli- 
cants. In a letter to their examiners they 
say: 

"The statistics on 1,247 cases at all 
ages, in which there was a blood-pressure 
of 150 mm. mercury and over, show a mor- 
tality two and one-half times greater than 
the general average mortality of the com- 
pany covering the same period. In 891 of 
these cases there was no other impairment 
recorded in the application when received 



128 BLOOD PRESSURE 

at the home office. All these risks would 
have been granted insurance had not 
blood-pressure been taken. A careful 
study of the statistics of this company 
demonstrates, without a doubt, that the 
use of the sphygmomanometer is indis- 
pensable in our examination for life insur- 
ance. The statistics also demonstrate, in 
our opinion, that the use of the sphyg- 
momanometer will be of equal value to the 
practitioner in his general practice, and 
that no physician should be without this 
valuable aid in diagnosis. 

"We feel, therefore, that it is not un- 
reasonable to require the examiners of this 
company to procure an instrument and 
furnish the company with the blood-pres- 
sure in all examinations they make, regard- 
less of the age or amount of insurance ap- 
plied for. We shall expect, therefore, our 
examiners, who do not at this time pos- 
sess a sphygmomanometer or have the use 
of one, to provide themselves with the in- 
strument to enable them to comply with 
the rules of the company.' ' 



IN GENERAL PRACTICE 129 

In taking blood-pressure in this class of 
cases there are several important factors 
to be considered, more fully discussed in 
the section on Physiological Variations 
(see page 50), but it might be well to re- 
peat them. It is often well to adjust the 
pneumatic cuff to the patients, but not 
take the pressure reading for some min- 
utes, in the meantime obtaining what data 
is desired from the patient, as many per- 
sons are nervous and under a mental 
strain when being examined. In this way 
you largely eliminate the nervous excite- 
ment and mental tension, which will often 
raise the pressure 10 or more millimeters. 

The cuff should be adjusted at the heart 
level, the patient in a comfortable position 
with muscular relaxation and breathing 
quietly. 

Pressure readings are preferably taken 
midway between meals. Make the actual 
determination as rapidly as possible, as 
prolonged constriction of the arm ma- 
terially raises the tension (do not take 
over 1-3 minutes). 



130 BLOOD PEESSUEE 

Make it a rule to take all observations 
on your applicants in the same position, 
either in the sitting or reclining posture. 

As mental work and stimuli markedly 
raise the pressure, which even judicious 
treatment during the examination will not 
always eliminate, if readings are too high 
without any apparent organic change, ask 
for a subsequent examination, when the 
patient has rested and is free from excit- 
ing stimuli. 

It is always best to obtain several read- 
ings and get an average. On numerous oc- 
casions business men have been examined 
during their working hours, and blood- 
pressure readings were found to be con- 
siderably too high, but the same men after 
a few hours rest have had a normal 
blood-pressure and have been accepted 
without a doubt in the mind of the ex- 
aminer. In some cases, if the tension is 
still high or the readings are on the bor- 
der line, it is important to take a number 
of readings. 

Aside from these general precautions 



IN GENERAL PRACTICE 131 

there are not any factors influencing blood- 
pressure readings to any marked degree. 
Even age, which has been greatly empha- 
sized in the past, is not a great factor. 
The status of age in relation to blood- 
pressure is clearly expressed by Dr. Henry 
Wireman Cook: 

"Age after childhood is constantly as- 
suming a less and less important place as 
a factor in normal blood-pressure varia- 
tions. In early observations high blood- 
pressure at older ages was found of so 
much greater relative frequency that prac- 
tically all observers were led into the be- 
lief that much higher blood-pressures were 
normal at the older ages than is actually 
the case. This partly rose from the use of 
a narrow arm-piece, which unduly empha- 
sized any increase, but probably in most 
part the mistake was due to the fact that 
the cardiovascular and renal changes are so 
much more common after forty-five. Later 
and more accurate observations, however, 
showed that there is very little normal in- 
crease in the blood-pressure before sixty 



132 BLOOD PRESSURE 

years of age, and when a marked hyper- 
tension is present it is associated with a 
distinct abnormality of tissue function. 
Authoritative data on this subject are 
most convincing.' ' 

In over two hundred consecutive blood- 
pressure observations Janeway saw 145 
mm. Hg exceeded only once or twice, ex- 
cept where cause for hypertension existed. 
In routine examinations of many hundreds 
of cases he never saw a pressure above 160 
mm. in a normal person — seldom one 
above 140 mm. (wide arm-piece). He re- 
gards with suspicion any pressure over 
145 mm. His later statement, March, 
1911, is "A blood-pressure reading of 
more than 145 mm. before middle life or 
of more than 160 mm. after must be con- 
sidered abnormal.' [ 

Before closing I wish to call attention to 
some aspects of blood-pressure in relation 
to life-insurance examination, which in the 
past have received very little attention : 

First, the value in doubtful cases of the 
use of the functional test of the myocar- 



IN GENERAL PRACTICE 133 

dium, by a regulated amount of exercise 
with blood-pressure readings (see Heart 
Diseases, page 77). 

Second, the importance of routinely tak- 
ing the diastolic blood-pressure as well as 
the systolic, as the pulse pressure (dif- 
ference between the systolic and the dias- 
tolic) is often invaluable in determining 
the amount of arteriosclerosis present; as 
already has been described there are a 
number of patients in whom the systolic 
pressure is at the normal level, but who 
have had a high systolic pressure until the 
myocardium has given away and the hy- 
pertension could no longer be maintained. 
Here the diastolic pressure remains rela- 
tively high, giving a small pulse pressure 
and making the diagnosis of arteriosclero- 
sis, with associated myocarditis. 

More attention should be paid to hypo- 
tension, in relation to tuberculosis. 

Diseases to consider are: chronic inter- 
stitial nephritis, cardiac diseases, arterio- 
sclerosis, angina sclerosis and tuberculosis. 



BIBLIOGRAPHY 

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135 



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Peter, L. C. Arterial hypertension and its re- 
lation to morbid changes in the eye. Penn. 
Med. Journal, March, 1911. 

Robinson, G. C. Blood pressure in epidemic 
cerebro-spinal meningitis. Archives of In- 
ternal Medicine, Chicago, May, 1910. 

Rudolph, R. D. High blood pressure in 
arteriosclerosis. British Medical Journal, 
November 26, 1910. 

Sheldon, W. H. Long continued high blood 
pressure, its results and prevention. Medi- 
cal Record, December 31, 1910. 

Starling, H. J. Value of blood pressure deter- 
minations in the toxemia of pregnancy. 
London Lancet, September, 1910. 

Swan, John M. Influence of carbonated 
brine baths (Nauheim) on blood pressure. 
Archives of Internal Medicine, August 15, 
1912. 

Visscher, L. G. Treatment of chronic hyper- 
tension. Journal of Amer. Med. Associa- 
tion, December 2, 1911. 

Voyler, W. J. The blood pressure during 



140 BIBLIOGRAPHY 

pregnancy and the puerperium. Amer. Jour- 
nal of Obstetrics, Vol. LX, 1907. 

Warfield, Louis N. The osculatory blood pres- 
sure phenomenon. Interstate Med. Journal, 
October, 1912. 

Studies in auscultatory blood pressure phe- 
nomena. Journal American Med. Association, 
October 4, 1913. 

Wiggers, C. J. Prognostic significance of pulse 
pressure changes during hemorrhage. Arch- 
ives of Internal Medicine, September, 1910. 

Wo ole y, H. P. Normal variation of systolic 
blood pressure. Journal American Med. As- 
sociation, July 9, 1910. 



INDEX 

Acidosis (with hypertension), 

cereal diet in, 100. 
Aconite, 

effect on blood pressure, 101. 
hypotension from, 108. 
in toxemia of pregnancy, 101. 
Adrenalin, hypertension from, 68. 
in pneumonia, 111. 
in shock and collapse, 119. 
Age, blood pressure variations in, 48, 49, 131. 
Alcohol, effect on blood pressure, 107. 
hypertension from, 107. 
hypotension from, 107. 
in typhoid fever, 114. 
Alcoholic delirium, blood pressure, 
readings in, 115 
hypotension in, 115. 
Altitude, effect on blood pressure, 52. 
effect on cardiac cases, 53 
effect on phthisis, 54. 
Anemia, blood pressure in, 106. 

hypotension in, 106. 
Aneroids, 23, 24, 25, 26, 28. 
Anesthesia, blood pressure in, 121, 122. 
value of blood pressure, 
readings in, 122. 
Anger, effect on blood pressure, 52. 

141 



142 INDEX 

Angiosclerosis, definition of, 59 

diagnostic importance of, 59. 
treatment in, 59, 60. 
Angina pectoris, blood pressure readings in, 60, 61. 
chloral hydrate in, 98, 99. 
diagnosis of, 60, 61. 
symptoms of, 60, 61. 
Aortic regurgitation, auscultation method in, 78. 

blood pressure readings in, 77. 
difference between brachial and 

femoral readings in, 78. 
diastolic pressure in, 78. 
hypertension in, 77, 78. 
Apoplexy, blood pressure readings in, 83. 
cause of hypertension in, 83. 
diagnostic use of blood pressure in, 83. 
treatment of, 83. 
Arm bands, location of, in relation to blood pressure, 50. 

width of, 3, 17. 
Arteries, determination of dilatation of, 43. 
Arteriosclerosis, 61-66. 

blood pressure readings in, 62. 

cerebral, diagnosis of, 64. 

diagnosis of, 61, 62. 

factors to consider in the diagnosis of, 62, 63. 

hypertension in, when associated disease, 65. 

hypertension of, treatment of, 99. 

iodides in the treatment of, 99, 101. 

measure of the degree of, 64. 

myocarditis in, 65, 66. 

primary, hypertension relation to, 62, 63. 

result of hypertension, 56, 63. 

routine blood pressure to determine the onset of, 

64, 65. 
senile, blood pressure in, 64. 



INDEX 143 

Arteriosclerosis, syphilitic, iodides in the treatment of, 

99. 
Asphyxia, effect on blood pressure, 55. 
Aspiration of serous fluid, blood pressure in, 123. 
Asthma (cardiac), hypertension in, 78-79 
Atropine, effect on blood pressure, 70. 
Auscultation method, intensity of sounds and significance 
of, 12. 
on what based, 13, 14. 
sounds and phases, 11, 12, 13. 
the determination of systolic and 
diastolic pressure by, 9, 10, 33. 
Autointoxication, 66, 67. 

Baths, electric light in the treatment of hypertension, 103. 
hot air in treatment of toxic hypertension, 100. 
oxygen, in the treatment of hypertension, 103. 
treatment of hypertension, 97. 
typhoid fever, their use and effect on blood pres- 
sure, 114. 
Bendick air water blood pressure apparatus, 23. 
Bibliography, 135-140. 
Bier's hyperemia, 37 . 
Bleeding, in acute toxic hypertension, 101, 102. 

in hypertension, apoplexy imminent, 101. 
in pneumonia, 110. 
Blood, velocity of flow, 45. 

volume of, relation to blood pressure, 45. 
Blood pressure, abnormal, 48. 

age, effect of, 131. 

age, readings at different periods, 48, 49. 

auscultatory, sounds and phases, 11, 12, 

13. 
cases of value in, 5. 
definition of, 7. 



144 INDEX 

Blood pressure, diastolic, measurement of, 9, 10. 
divisions of, 7. 
drugs elevating, 67-70. 
drugs lowering, 107-108. 
effect of aconite, 101-108. 
effect of adrenalin, 68. 
effect of alcohol, 107. 
effect of atropine, 70. 
effect of caffein, 70. 
effect of camphor, 68. 
effect of chloral hydrate, 108. 
effect of chloroform, 108. 
effect of cocaine, 68. 
effect of coffee, 70. 
effect of digitalis, 68. 
effect of ergot, 70. 
effect of iodides, 108. 
effect of nitrites, 108. 
effect of pituitary extract, 70, 108. 
effect of saline solution (normal), 69. 
effect of strychnia, 69, 70. 
effect of tobacco, 70, 107. 
effect of thyroid^extract, 108. 
exercise, effect on, 

in normal cases, 51. 

in myocarditis, 79-80. 
in treatment of, 97. 
factors on which it depends, 38, 39, 40. 
from manipulation during operation, 126. 
high and maintained, effect of, 56. 
historical review of, 1-4. 
hypertension, 56-105. 
hypotension, 105-120. 
importance of, and conditions to which 
it applies, 4-7. 



INDEX 145 

Blood pressure, in alcoholic delirium, 115. 

in anemia, 106. 

in anesthesia, 121, 122. 

in angina pectoris, 60, 67. 

in angiosclerosis, 59, 60. 

in aortic regurgitation, 77. 

in apoplexy, 82, 83. 

in arteriosclerosis, 61-66. 

in asphyxia, 55. 

in autointoxication, Q6 } 67. 

in bradycardia, 81. 

in carcinoma of the stomach, with vom- 
iting, 107. 

in cardiac arrhythmia, 81. 

in cardiac conditions (acute), 106. 

in cardiac failure and asthma, 78-79. 

in cardiac hypertrophy (chronic), 78. 

in cardiac valve lesions, other than aortic, 
78. 

in cataract, 74. 

in cerebral thrombosis, 83. 

in cerebrospinal meningitis, 108. 

in cholera, 106, 107. 

in collapse, 118, 119. 

in collapse, premonitory sign of, in opera- 
tions, 124. 

in concussion of brain, 83. 

in diabetes, 67. 

in diarrhoea, 106, 107. 

in diphtheria, 109. 

in diseases with marked loss of fluid, 
106, 107. 

in dysentery, 106, 107. 

in eclampsia, 86, 89. 

in edema, 55. 



146 



INDEX 



Blood pressure, 



n endocarditis (acute), 81. 

n epilepsy, idiopathic, 70-71. 

n epilepsy, Jacksonian, 82-83. 

n exophthalmic goiter, 71. 

n eye diseases, 71-77. 

n fracture of the skull (base), 82, 83. 

n fracture of the skull (depressed), 82, 83. 

n glaucoma, 76. 

n gout, 77. 

n hemorrhage, extensive, 108. 

n hemorrhage, intracranial, 82, 83. 

n hysteria, 116. 

n infectious diseases, acute, 108, 109. 

n infections of children, acute, 115. 

n insomnia, 116. 

In intestinal obstruction (with vomiting), 

107. 
in life insurance, 127, 133. 
in mania, acute, 107. 
in melancholia, 107. 
in myocarditis, 79. 
in nephritis, 83-86. 
in nephritis, acute, 85-86. 
in nephritis, chronic interstitial, 84, 85. 
in nephritis, chronic parenchymatous, 85. 
in neuralgia, trifacial, 117. 
in neurasthenia, 116. 
in operations, treatment of, 125. 
in paresis, general, 116. 
in scarlet fever and nephritis complicat- 
ing, 112. 
in scarlatinal nephritis, 86. 
in obstetrics, 86-89. 
in operative surgery, value of, 124. 
in pericarditis, 106. 



INDEX 147 

Blood pressure, in peritoneal effusion, 123. 

in peritonitis, with vomiting, 107, 

in plumbism, 89-90. 

in phthisis, 117. 

in phthisis, chronic, 106. 

in pleural effusion, 123. 

in pneumonia, 110-111. 

in pregnancy, 86-89. 

in pregnancy, toxemia of the first half, 

with pernicious vomiting, 87. 
in pregnancy, toxemia of the last half, 87. 
in retinal hemorrhage, 76. 
in rheumatism, acute articular, 112. 
in shock, 118-119. 
in shock, post-operative, 123. 
in spasm of the retinal vessels, 73. 
in spinal anesthesia, 122. 
in surgery, operative procedures, 122-126. 
in syphilis, acute, 119. 
in syphilis, chronic. See arteriosclerosis, 

59-60. 
in tabes dorsalis, 119, 120. 
in tumors, cerebral, rapid growing, 82, 83. 
in typhoid fever, 112-114. 
in uremia, 86. 

in wasting diseases, chronic, 106. 
instruments, aneroid, spring-diaphragm 
or dial, discussion of, 23-26. 

Benedick air-water, 23. 

v. Bosch, 2. 

Brown, 21. 

choice of, 17, 18. 

classification of, 18, 19. 

Cook, description of, and cut, 
19, 20. 



148 INDEX 

Blood pressure, instruments, Erlanger, 37. 
Faught, 21. 
Hertz, 23. 
Janeway, description and cut, 

21, 22. 
Martin, 21. 
Mercer, 21. 

mercurial, 18-23, 26, 27-37. 
Nicholson, description and cut, 

26, 27. 
New Nicholson pocket, description 

and cuts, 28-37. 
Oliver, 23. 
Pachon, 37. 
Riva-Rocci, 2, 3, 19. 
Roger's simplex, 23. 
Sahli, 21. 
Sands, 19. 
Stanton, description and cut, 19, 

20. 
Uskoff, 37. 
low limit, 48, 99. 

maintenance of, mechanics, 39, 40. 
methods of measuring, 8. 
normal readings, adults and children, 47. 
physiologic variation, due to altitude, 52, 

53, 54. 
physiologic variation, due to breathing, 51. 
physiologic variation, due to exercise, 51, 

52. 
physiologic variation, due to location of 

cuff, 50. 
physiologic variation, due to meals, 51. 
physiologic variation, due to nervous and 
mental stimuli, 52. 



INDEX 149 

Blood pressure, physiologic variation, due to position of 

patient, 50, 51. 
physiologic variation, due to time taken 

in making readings, 54. 
physiologic variation, summary of, 54, 55. 
routine determination of, and its value, 

46, 47, 58. 
routine observation of, and importance in 

surgical shock, 123-126. 
systolic, measurement of, 8, 9. 
value of, in physical diagnosis, 6. 
variation in, due to asphyxia, 55. 
variation in, due to edema, 55. 
Bosch, v., instrument of, 2. 
Bradycardia, blood pressure in, 81. 

Caffein, effect on blood pressure, 70. 
Camphor, effect on blood pressure, 68. 

in pneumonia, 111. 
Cancer, blood pressure in, 106. 
hypotension in, 106. 
of stomach, with profuse vomiting, 107. 
Cardiac arrhythmia, functional or organic, 81, 82. 

hypertension in, 82. 
Cardiac conditions (acute), blood pressure in, 106. 

hypotension in, 106. 
Cardiac failure and asthma, blood pressure in, 68, 69. 
Cardiac failure, in nephritis, 85. 

in pneumonia, 111. 
Cardiac hypertrophy, blood pressure in, 78. 

result of hypertension, 56. 
Cataract, blood pressure in, 74, 75. 

blood pressure determination in, before opera- 
tion, 74. 
prevention of post-operative hemorrhage in, 74. 



150 INDEX 

Cereal diet in treatment of hypertension, 100. 

Cerebral concussion, diagnosis of, 83. 

Cerebral thrombosis, blood pressure readings in, 83. 

hypertension compensatory in, 83. 
treatment of, 83. 
Cerebrospinal meningitis (epidemic), 108. 
Children, blood pressure readings in, 48. 
Chloral hydrate, hypotension from, 108. 

in angina pectoris, 98, 99. 
in treatment of hypertension, 99. 
in psychic hypertension, 99. 
Chloroform, effect on blood pressure, 121. 

hypotension from, 108. 
Cholera, hypotension in, and cause of, 107. 

value of blood-pressure determinations in, 107. 
Cocaine, effect on blood pressure, 68. 

hypotension from, and maintenance of, 119. 
in collapse, 119. 
in shock, 119. 

in shock, prophylactic treatment of, 123. 
in spinal anesthesia, effect on blood pressure, 
122. 
Coffee, effect on blood pressure, 70. 
Collapse, adrenalin intravenously in, 119. 
blood pressure in, 118, 119. 
cocaine in, 119. 

hypotension in, cause of, 118, 119. 
in anesthesia, 122. 

premonitory signs of, in surgical conditions, 124. 
treatment of, 119. 
Concussion of the brain, differential diagnosis of, 83. 
Cook, H. W., blood pressure instrument of, 19, 20. 

Diarrhoea, hypotension in, and cause of, 107. 

value of blood pressure determinations in, 107. 



INDEX 151 

Diastolic pressure, auscultatory method of obtaining, 25. 
definition of, 7. 
discussion of, 41-46. 
in aortic regurgitation, 77, 78. 
in life insurance, 133. 
measurement of, 9, 10, 31, 32, 33. 
normal reading, 47. 
relation of blood vessels to, 62. 
relation to pulse rate, 42. 
value of, 41, 42. 
Diet, in the treatment of hypertension, 91, 92. 
Digitalis, dosage and effect on blood pressure, 114. 
effect on blood pressure, 63. 
in collapse, 119. 
in pneumonia, 111. 
in shock, 119. 

in senile hearts, with hypertension, 100. 
in typhoid fever, 114. 
in the treatment of hypertension, 100. 
value in raising blood pressure, 68. 
Diphtheria, hypotension in, 109. 

value of blood pressure readings in, 109. 
Drugs, causing hypertension, 67-70. 

causing hypotension, 107, 108. 
Dysentery, hypotension in, and cause of, 107. 

value of blood pressure determinations in, 107. 

Eclampsia, blood pressure in, 86-89. 

Edema, effect on blood pressure, 55. 

Electricity in, treatment of hypertension, 102, 103. 

Electric-light baths, Jin the treatment of hypertension, 103. 

Endocarditis (acute), hypotension in, 82. 

Erlanger, blood pressure instrument of, 37. 

Epilepsy, idiopathic, differential diagnosis of, 71. 

Jacksonian, blood pressure readings in, 82, 83. 



152 INDEX 

Ergot, effect on blood pressure, 70. 

Erythrol tetra-nitrate, in hypertension, dose, etc., 102. 

Ether, effect on blood pressure, 121. 

Exercise, effect on blood pressure in myocarditis, 79, 80. 

effect on blood pressure in normal cases, 51. 

in treatment of hypertension, 97. 

in treatment of hypotension, 120. 
Exophthalmic goiter, blood pressure in, 71. 
Eye diseases, blood pressure in, 71-77. 

routine blood pressure readings, 
importance of, 71, 72. 

Faught, blood pressure instrument of, 21. 
Females, blood pressure readings in, 48. 

Gibson's rule, in pneumonia, 110. 

Glaucoma, hypertension in, 76. 

Graupner test, for myocarditis, 77-79. 

Gout, hypertension in, 77. 

Gymnastics, in the treatment of hypertension, 104. 

Hemorrhage, extensive, hypotension from, 108. 

in typhoid fever, 113. 

intracranial, blood pressure in, 82, 83. 

intracranial, differential diagnosis in, 83. 

intracranial, hypertension in, 83. 

intracranial treatment in, 83. 

retinal, blood pressure in, 76. 

treatment of, normal saline solution, 69. 
Head injuries, differential diagnosis in, 83. 
Headaches, in autointoxication, 66. 
Heart, brown atrophy, the cause of hypotension, 106. 
Heart diseases, blood pressure in, 77-82. 
disease (acute), hypotension in, 106. 
effect of altitude in, 53. 



INDEX 153 

Heart, relation of each contraction to the blood pressure 
reading, 14-16. 
strength of, relation to blood pressure, 38. 
weakness, determination of, 43. 
Hertz, blood pressure instrument of, 23. 
Hot packs in alcoholic delirium, 115. 
Hydrotherapy, in the treatment of hypotension, 120. 
Hygiene (general) in the treatment of hypotension, 120. 
Hypertension, 56-105. 

cardiac hypertrophy in, 56. 

causes of, 56, 57. 

compensatory, 90. 

diseases with, 59-90. 

drugs causing, 67-70. 

early diagnosis of, importance of, 57. 

exercise in the treatment of, 97. 

from alcohol, 107. 

from ether, 121. 

from tobacco, 107. 

general consideration of, 56-58. 

in angina pectoris, 60, 61. 

in angiosclerosis, 59, 60. 

in aortic regurgitation, 77, 78. 

in apoplexy, 82, 83. 

in arteriosclerosis, 61-66. 

in asphyxia, 64. 

in autointoxication, 66, 67. 

in bradycardia, 81. 

in cardiac arrhythmia, 81. 

in cardiac failure and asthma, 78-79. 

in cardiac hypertrophy, 78. 

in cataract, 74, 75. 

in cerebral thrombosis, 82, 83. 

in eclampsia, 86-89. 

in edema, 55. 



154 INDEX 

Hypertension, in epilepsy, idiopathic, 70, 71. 
in epilepsy, Jacksonian, 82, 83. 
in exophthalmic goiter, 71. 
in eye diseases, 71-77. 
in glaucoma, 76. 
in gout, 77. 

in hemorrhage (extensive), 82, 83. 
in increased intracranial tension, 82, 83. 
in myocarditis, 81. 

in nephritis, chronic interstitial, 84-85. 
in nephritis, chronic interstitial, in relation 

to the eye, 75. 
in obstetrics, 86-89. 
in peritoneal effusion, 123. 
in phthisis, 117, 118. 
in pleural effusion, 123. 
in plumbism, 89, 90. 
in retinal hemorrhage, 76. 
in scarlatinal nephritis, 86, 112. 
in spasm of the retinal vessels, 73, 74. 
in senile hearts, 100. 
in skull, fracture of, base, 82, 83. 
in skull, fracture of, depressed, 82, 83. 
in typhoid fever, perforation in, 113-114. 
in tumors, cerebral, rapid-growing cerebral, 

82, 83. 
in uremia, 86. 

inability to determine by palpation, 82. 
increasing frequency of, due to, 56, 57. 
primary, 57. 

psychic, treatment of, 99. 
relation to pulse pressure, 43. 
routine blood pressure determination to 

detect, 58. 
treatment of, 90-104. 



INDEX 155 

Hypertension, treatment of, aconite in, 101. 

treatment of, alkali by rectum in, 94. 
treatment of, bathing in, 97. 
treatment of, hot baths in, 100. 
treatment of, baths, oxygen in, 103. 
treatment of, bromides in, 99. 
treatment of, cereal diet in, 100. 
treatment of, chloral hydrate in, 98, 99. 
treatment of, diet in, 91, 92. 
treatment of, digitalis in, 100, 
treatment of, electricity in, 102, 103. 
treatment of, exercise in, 97. 
treatment of, factors involved in, 92, 93. 
treatment of, immediate, 93, 94. 
treatment of, in increased intra-abdominal 

pressure, 95, 96. 
treatment of iodides in, 98, 99. 
treatment of, laxatives in, and the time to 

be given, 94. 
treatment of, mercury salts in, 100, 101. 
treatment of, nitroglycerine in, 101-103. 
treatment of, obesity in relation to, 90, 

91. 
treatment of, prophylaxis, 90, 91. 
treatment of, rest after meals, 98. 
treatment of, rest (absolute) with milk diet 

and massage, 100. 
treatment of, salt intake in, 100. 
treatment of, sleep in, 97. 
treatment of, thyroid extract in, 103. 
treatment of, venesection in, 100, 101. 
treatment of, vasodilators in, 102, 103. 
treatment of, wet pack in (neurasthenia) 

104. 
vascular changes from, 56. 



156 INDEX 

Hypertension, with proportionately high diastolic pressure 

relation to circulation, 43. 
Hypotension, 105-120. 

caused by, 105, 106. 

definition of, 105. 

general consideration of, 105, 106. 

from alcohol, 107. 

from cerebrospinal meningitis, 108. 

from chloroform, 121. 

from syphilis (acute), 119. 

from tobacco, 107. 

importance of, 105. 

in alcoholic delirium, 115. 

in anesthesia, treatment of, 122. 

in carcinoma of the stomach, 107. 

in cardiac conditions (acute), 106. 

in cholera, 106, 107. 

in collapse, 118, 119. 

in diphtheria, 109. 

in dysentery, 106, 107. 

in diarrhoea, 106, 107. 

in diseases with marked loss of fluid, 106, 
107. 

in endocarditis (acute), 81. 

in hemorrhage, extensive, 108. 

in infectious diseases (acute), 108, 109. 

in infections of children (acute), 115. 

in insomnia, 116. 

in intestinal obstruction, with vomiting, 107. 

in life insurance, 133. 

in melancholia, 116. 

in neuralgia, trifacial, 117. 

in paresis, general, 116. 

in mania (acute), 116. 

in operations, treatment of, 125-126. 



INDEX 157 

Hypotension, in pericarditis, 106. 

in peritonitis (vomiting), 107. 

in pneumonia, 110, 111. 

in rheumatism (acute articular), 112. 

in scarlet fever, 112. 

in shock, 118, 119. 

in spinal anesthesia, 122. 

in typhoid fever, 112, 113. 

in typhoid fever, in hemorrhage in, 113. 

in wasting diseases (chronic), 106. 

relation to cardiac weakness, 43. 

relation to dilated arteries, 43. 

treatment of, exercise in, 120. 

treatment of, hydrotherapy in, 120. 

treatment of, laxatives in, 120. 

treatment of, massage in, 120. 

treatment of, nux vomica in, 120. 

treatment of, pituitrin in, 120. 

vasomotor tension in, 105, 106. 
Hysteria, blood pressure in, 116. 

Indicanuria, in autointoxication, 67. 

in the treatment of hypertension, 93. 
Inertia of mercury, relation to accuracy of readings, 14, 

15. 
Infectious diseases (acute), hypotension in, 108, 109. 
Infections of children (acute), blood pressure low limit in, 

115. 
blood pressure in treatment 

of, 115. 
prognosis in, 115. 
Insomnia, hypertension in, 116. 
hypotension in, 116. 
treatment of, 116. 
vasodilators in, 116. 



158 INDEX 

Intestinal obstruction (with vomiting), hypertension in, 
107. 
value of blood pressure determina- 
tion in, 107. 
Intra-abdominal tension (increased), treatment of, 95, 96* 
causes of, 95. 
hypertension in, 95. 
Intracranial tension, increased, hypertension in, 82, 83. 
Iodides, hypotension from, 108. 

in arteriosclerosis, 99, 101. 

in senile hearts with hypertension, 100. 

in syphilitic arteriosclerosis, treatment of, 99. 

in the treatment of hypertension, 99-101. 

in the treatment of hypotension, 98, 99. 

Janeway, T. H., blood pressure instrument of, 21, 22. 

Korotkow, auscultation method of, 8. 
Kymographion, the, 1. 

Laxatives, in the treatment of hypertension, 94. 
in the treatment of hypotension, 120. 
life insurance, age in effect on blood pressure readings, 
131, 132. 
blood pressure in, 127-133. 
blood pressure readings factors to consider 

in obtaining, 129, 130. 
blood pressure readings limits of, 132. 
blood pressure statistics in, 127, 128. 
diastolic pressure, the importance of, 133. 
diseases to consider, 133. 
hypotension in, 133. 
myocarditis, functional test of, 133. 
pulse pressure in, importance of determin- 
ing, 133. 



INDEX 159 

Life insurance, sphygmomanometer, value of, 128. 
Ludwig, instrument of, kymographion, 1. 

Mania (acute), hypotension in, 116. 
Marey, blood pressure instrument of, 1. 
Martin, blood pressure instrument of, 21. 
Massage, in the treatment of hypertension, 104. 
in the treatment of hypotension, 120. 
Meals, influence on blood pressure, 52. 
Mean pressure, definition of, 7. 
Melancholia, hypertension in, 116. 

treatment^, 116. 
Meningitis, blood pressure in, 108. 
Mental stimuli, effect on blood pressure, 52. 
Mercer, blood-pressure instrument of, 21. 
Mercurial, blood-pressure instruments, 18-23, 26-37. 
Mercury, inertia of and relation to accuracy of readings, 
14, 15, 32, 33. 
oscillation of the column, significance of, 14, 15, 

32, 33. 
salts of, in the treatment of hypertension, 100, 

101. 
salts of, in the treatment of toxic hypertension, 
100, 101. 
Myocarditis, blood pressure in, 79-81. 
functional test of, 79, 80. 
sequel to arteriosclerosis, 65, 66. 

Nephritis, 83, 86. 

acute, blood pressure in, 85, 86. 
cardiac failure in, 85. 

chronic interstitial, in relation to the eye, 75. . 
chronic interstitial, readings in, 84, 85. 
chronic interstitial, pulse pressure in, 84, 85. 
chronic parenchymatous, blood pressure in, 84, 
85. 



160 INDEX 

Nephritis, scarlatinal, hypertension from, 86. 

Nervous stimuli, effect on blood pressure, 52. 

Neuralgia, trifacial, hypertension in, 117. 

Neurasthenia, blood pressure in, 116. 

treatment of, wet pack in, 103. 

Neurological conditions, 115-117. 

Nicholson, P., blood pressure instrument of, 26, 27. 

Nicholson, P., new pocket blood pressure instrument of, 28, 
37. 

Nitrites, hypotension from, 108. 

Nitrites in the treatment of senile hearts with hyperten- 
sion, 100. 

Nitrites, permanency and symptoms caused by, 102, 103. 

Nitroglycerine, in hypertension, dose, duration and toler- 
ance, 102, 103. 

Nitrous oxide, effect on blood pressure, 121. 

Obesity, treatment of, when associated with hypertension, 

95, 96. 
Oscillation of the mercury column, in relation to accuracy 

of readings, 14, 15, 32, 33. 
Obstetrics, blood pressure in, 86-89. 
Oxygen baths in the treatment of hypertension, 103. 

Pachon, blood pressure instrument of, 37. 

Pain, effect on blood pressure, 52. 

Palpation method of blood pressure, 8, 9. 

Paresis, general, blood pressure in, 116. 

Psychic hypertension, treatment of, oxygen baths in, 103. 

Pericarditis, blood pressure in, 106. 

hypotension in, 106. 
Peripheral resistance, relation to blood pressure, 38. 
Peritoneal effusion, blood pressure in the aspiration of, 
123. 
hypertension from, 123. 



INDEX 161 

Peritonitis (with vomiting), hypotension in, 107. 

value of blood pressure determination in, 107. 
Phthisis, blood pressure readings in, 117. 

blood pressure, value of, in the diagnosis of, 117, 

118. 
blood pressure variations in, significance of, 117, 

118. 
continued hypotension in, 118. 
effect of altitude in, 54. 
chronic, blood pressure in, 106. 
hypotension, significance of, in prophylaxis, 118. 
Pituitary extract, danger of use of, 70. 

effect on blood pressure, 70. 
hypotension from, 108. 
Pleural effusion, blood pressure in the aspiration of, 123. 

hypertension from, 123. 
Plumbism, blood pressure in, 89, 90. 
Pneumatic cuff, location of, effect on blood pressure, 50. 
Pneumonia, adrenalin in, 110. 

blood pressure in, 110-112. 

blood pressure in the treatment of, 111, 112. 

blood pressure variations in, 110, 111. 

camphor in, 111. 

cardiac failure in, 111. 

cardiac or vascular failure, diagnosis of, 111. 

digitalis in, 111. 

Gibson's rule in, 110. 

drugs in, 111. 

hypertension and hypotension in, causes of, 

110, 111. 
vasomotor paralysis in, 110, 111. 
venesection in, 110, 111. 
Poiselli, blood pressure instrument of, 1. 
Pneumatic cuff, width of, 3, 17. 
Position of patient, influence on blood pressure, 50, 51. 



162 INDEX 

Pregnancy, blood pressure in, 86, 89. 
normal readings in, 86, 87. 
pernicious vomiting, blood pressure in, 87. 
Psychic hypertension, treatment of, 99. 
Ptoin, v., blood pressure instrument of, 2. 
Pulsations of the heart, relation to blood pressure readings, 

14-16, 32, 33. 
Pulse pressure, definition of, 7. 

discussion of, 41-46. 

in arteriosclerosis, with myocarditis, 65, 66. 

in aortic regurgitation, 77, 78. 

in chronic interstitial nephritis, 84, 85. 

in pneumonia, importance of, 110. 

large, relation to arterial dilatation, 43. 

normal readings in, 41. 

per cent, of systolic pressure, 41. 

relation of blood vessels to, 42. 

relation of strength of heart to, 43. 

relation to pulse rate, 42. 

relation to velocity of blood, 44. 

small, meaning of, 44. 

small, relation to heart weakness, 43. 

the head pressure, 40. 

value of, 43-45. 

with high systolic and proportionate 
diastolic pressure, 43. 
Pulse rate, relation to pulse pressure, 42. 

Rest, in the treatment of hypertension, 100. 

in the treatment of psychic hypertension, 99. 
Retinal hemorrhage, hypertension the cause of, 76. 
Retinal vessels, spasm of, blood pressure in, 73. 

symptoms and treatment of, 73, 74. 
Reservoir type, blood pressure instruments, 18-21, 26, 
27-37. 



INDEX 163 

Rheumatism (acute articular), blood pressure in, 112. 
Riva-Rocci, blood pressure instrument of, 2, 3, 19. 
Roger's simplex, blood pressure instrument, 23. 

Sahli, blood-pressure instrument of, 21. 
Saline solution (normal), effect on blood pressure in hem- 
orrhage, 69. 
effect on blood pressure in shock, 

69. 
intravenously in collapse, 119. 
intravenously in shock, 119. 
in treatment of and prevention 
of shock, 125, 126. 
Salt, in the treatment of hypertension, 100. 
Sands, blood pressure instrument of, 19. 
Scarlet fever, blood pressure in, 112. 
hypertension in, 112. 
hypotension in, 112. 
nephritis in (hypertension), 86. 
Serous effusions, blood pressure in, 123. 
Shock, adrenalin intravenously in, 119. 
blood pressure in, 118, 119. 
cocaine in, 119. 

hypotension in, cause of, 118, 119. 
in anesthesia, 122. 
normal saline solution in, 69. 
prevention of, cocaine for, 123. 
prophylaxis in operative cases, cocaine in, 123. 
surgical blood pressure in the diagnosis of, 123. 
treatment of, 119. 

treatment of, in operative cases, use of saline solu- 
tion, 125, 126. 
Skull, depressed fracture of, blood pressureln, 83. 

depressed fracture of, differential diagnosis of, 83. 
depressed fracture of, hypertension in, cause of, 83. 



164 INDEX 

Skull, depressed fracture of, treatment of, 83. 

fracture of the base, blood pressure in, 83. 

differential diagnosis in, 83. 
hypertension in, and cause of, 

83. 
treatment of, 83. 
Sleep, in the treatment of hypertension, 97. 

influence on blood pressure, 51. 
Sodium nitrite, in hypertension, dose, duration, and toler- 
ance, 102. 
Sphygmomanometer, aneroid, 18, 23-37. 
v. Bosch, 13. 
Bendick, 23. 
Brown, 21. 

choice of, 17, 18, 27, 28. 
classification of, 18, 19. 
Cook, description and cut, 19, 20. 
dial, 18, 23-26, 28. 
diaphragm, 18, 23-26, 28. 
Erlanger, 37. 
Faught, 21. 
Hertz, 23. 

in life insurance, 128. 
in surgery, importance in, 124-126. 
Jane way, description and cut, 21- 

22. 
Martin, 21. 
Mercer, 21. 
Nicholson, description and cut, 26, 

27. 
New Nicholson pocket, description 

and cut, 27-37. 
Oliver, 23. 
Pachon, 37. 
Rogers simplex, 23. 



INDEX 165 

Sphygmomanometer, Sahli, 21. 
Sands, 19. 

Stanton, description and cut, 19, 20. 
U tube, discussion of, 22. 
Stanton, W. H., blood pressure instrument of, 19, 20. 
Strychnia, dose and effect on blood pressure, 124. 
dose to elevate blood pressure, 69, 70. 
effect on blood pressure, 69, 70. 
duration of hypertension from, 69, 70. 
in collapse, 119. 
in pneumonia, 111. 
in shock, 119. 
in typhoid fever, 114. 
value of, to elevate blood pressure, 69, 70. 
Sulphonal, in insomnia, 116. 

Surgery, blood pressure in, post-operative, value of, 123. 
blood pressure observations before operation, 

value of, 123. 
operative, blood pressure in, 122-126. 
operative, blood pressure reading, indicating need 

for active interference, 125. 
routine blood pressure in, importance of, 123, 126. 
shock in, prophylaxis of, 125. 
Syphilis, blood pressure in, 129. 

hypotension from, in acute, 129. 
Syphilitic arteriosclerosis, iodides in the treatment of, 99. 
Systolic pressure, abnormal readings in, high and low, 48, 
49. 
definition of, 7. 

high, relation to pulse pressure, 43. 
in aortic regurgitation, 77. 
indication of strength of the cardiac con- 
traction, 40. 
low, relation to dilated arteries, 43. 
low, relation to weak heart, 43. 



166 INDEX 

Systolic pressure, measurement of, 8, 9. 

normal readings of, 47, 48. 

relation to intraventricular pressure, 40. 

Tabes dorsalis, differential diagnosis of, 120. 

hypertension in gastric crises, 119, 120. 
hypotension in lightning pains of, 119, 120. 
Tea, effect on blood pressure, 70. 
Thyroid extract, hypotension from, 108. 
Tobacco, hypertension from, 107. 
hypotension from, 107. 
Toxemia of pregnancy, of the first half, with vomiting, 87. 
of the last half, 87. 
treatment of, 88, 89. 
Toxic hypertension, mercury salts in, 100, 101. 

treatment of, 100, 101. 
Trional in insomnia, 116. 
Typhoid fever, alcohol in the treatment of, 114. 

baths in, and their effect on blood pressure, 

114. 
blood pressure readings in, 112, 113. 
complications in, the diagnosis of, 113, 114. 
digitalis in, 114. 
hemorrhage in, 113. 
hypertension following, 115. 
hypotension in, 112, 113. 
perforation in, 113, 114. 
routine blood pressure in, 113. 
strychnia in, 114. 
Tumors, cerebral, rapid growing, blood pressure in, 83. 
hypertension in, and cause of, 83. 
treatment of, 83. 

Uremia, blood pressure in, 86. 

differential diagnosis from epilepsy, 71. 



INDEX 167 

Uskoff, blood pressure instrument of, 37. 

U-tube mercurial blood pressure instruments, 21, 22. 

Vascular wall, elasticity of, in relation to blood pressure, 39. 
Vasodilators, 102. 

in insomnia, 116. 

in pneumonia, 110. 

summary of effect in hypertension, 102, 103. 
Vasomotor paralysis in pneumonia, 110, 111. 
Velocity of the blood, determination of, 44. 
Venesection, in hypertension, apoplexy imminent, 101. 

in pneumonia, 111. 

in toxic hypertension, acute, 100, 101. 

in treatment of hypertension, 100, 101. 
Viscosity of the blood, relation to blood pressure, 39. 

Wasting diseases (chronic), hypotension in, 106. 
Wet pack, in the treatment of hypertension, 104. 
Worry, effect on blood pressure, 52. 



